10th Greek Australian Legal and Medical Conference
Mykonos, Greece 2005

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DOCTORS, PATIENTS AND LAWYERS: ARE WE ALL SPEAKING THE SAME LANGUAGE?

EXAMINING WHY PATIENTS SUE DOCTORS

Dr Vinay S. Rane

The negligence of a doctor during a procedure or consultation is not the sole reason for litigation. When medical records associated with claims were taken from a single large hospital and reviewed, it was found that 42 percent of the claims did not involve negligence.[1] If patients are not suing doctors for negligence, what drives patients to initiate proceedings against their doctor?

Negligence

The Harvard Medical Practice Study examined over 30,000 randomly selected hospitals for patients who experienced disabling injuries caused by medical treatment.[2] There was an identified adverse outcome in 3.7 percent of admissions and a quarter of them were due to medical negligence. Only one in eight cases of medical negligence were followed by claims. It was estimated that less than 2 percent of negligent injuries were followed by claims in the relevant period.[3] 2 out of 3 claims in the Harvard Study arose from patients with no adverse outcome or an adverse outcome not due to negligence.[4] Hence there is a poor correlation between medical negligence and a malpractice claim.[5,6,7] A review of medical records from California in 1974 with closed malpractice claims estimated that the incidence of adverse events resulting from malpractice exceeded the number of claims filed by 10 to 1.[8] The more recent Harvard study found a negligent adverse event to claim ratio of around 8 to 1.[9] A study conducted in 2,000 found the generalizability of these studies to be plausible.[10]

Competence

Similarly, litigation is not necessarily related to competence or the clinical outcomes provided by a doctor. There seems to be no evidence of a difference in clinical outcomes for those doctors who had never been sued, been sued once, sued for large payouts frequently or sued for small payouts frequently.[11] Even a German and Austrian study of radiologists which found that most of the cases related to a complication of an examination procedure stated that doctors were sentenced due to their poor explanation of the examination and its consequences.[12] However, frequently sued physicians were shown to be the object of complaint about the interpersonal care they provide even by their patients who do not sue.[13] Their complaints however, were not concerning the doctor's competence but their communication skills. Frequent complaints included that patients "felt rushed, never received explanations for tests and were ignored."[14]

Poor Communication

The Health Services Commissioner of Victoria reported in 1988 that 80 percent of complaints received related to poor communication.[15] Various studies identify a poor relationship with the physician, poor delivery of information and destructive communications as reasons leading to an increased propensity to sue.[16,17,18] Also, it has been shown that positive communication by physicians increase patients' perceptions of their competence. This in turn leads to a decrease in malpractice claim intentions.[19]

The decision to litigate often follows a perceived lack of caring in the delivery of health care.[20] Patients who have resorted to litigation commonly felt deserted and that the views of the family and themselves were devalued.[21] Other common responses were that they felt that their doctors delivered information poorly and failed to understand their and their family's perspective.[22] Many patients wanted an explanation and an apology, and indicated that an adequate explanation and an apology might have prevented them from suing.[23] Another study found that 50 percent of 263 patients who sued their doctor claimed that they were so "turned off" by the doctor that they wanted to sue him/her before the alleged event occurred.[24]

Disclosure

Even when an adverse event has occurred, often it is not the event itself but the poor communication following the event that leads to litigation.[25] Patients feel that there is an unwillingness of providers to divulge information about instances of substandard care.[26] Where explanations were given to patients who subsequently initiated litigation, less than 15 percent of explanations were considered satisfactory.[27] Physicians are often unwilling to disclose their mistakes and wish to distance themselves from errors by denial, blaming others or becoming "unavailable". [28,29,30] This is in direct contrast to research over the past 10 years which suggests that patients desire an acknowledgement from physicians of even minor errors, and that doing so may reduce the risk of punitive actions being taken by the patient [31]. An Australian study that looked at patients' complaints to the New South Wales Health Care Complaints Commission found that only a few patients were seeking compensation, more wanted acknowledgement of harm done.[32]

Mandatory Disclosure

Given these findings, it is not surprising that there has been recent discussion advocating mandatory disclosure of medical errors. Many doctors have resisted mandatory disclosure believing it to increase malpractice liability exposure.[33] Other articles have disputed that belief, suggesting that malpractice liability actually decreases with full disclosure.[34,35] However, a literature search of approximately 5,200 citations conducted in 2003 found that there has been no real-world analysis of the impact of a mandatory disclosure policy, as articles that suggest that full disclosure averts some law suits do not allow for an estimate of any additional lawsuits that might be created by mandatory disclosure of medical errors.[36]

Physician demographics

Given that the evidence above suggests that physicians are usually not sued when an adverse event caused by their negligence occurs and are often sued when they are not at fault, we must look into other reasons for filing a claim. Litigation may be undertaken for reasons other than error by the physician and may be related to characteristics of certain physicians.

Unfortunately, studies aiming to identify the characteristics of such doctors have often been contradictory. Certain specialties have a clear relationship with certain malpractice rates.[37,38,39] However, studies looking at other physician characteristics have all yielded contradictory conclusions. From this we can conclude that characteristics such as previous educational successes, continuing medical education efforts, board certification, site of medical school training, type of practice and measures of competency have little bearing on altering the risk of litigation.[40,41,42] A flaw with many of these studies was that they did not adjust their findings for specialty.[43]

A retrospective cohort study published in 1992 looked at 9,250 physicians who had been insured for at least two years, and analyzed their claims per year. The study found that male physicians were three times as likely to be sued as female physicians, even after correcting for other variables.[44] The main reason for this was felt to be that women interact more effectively with patients. The peak age at which doctors were sued was found to be 40 years old, but that doctors were commonly sued anywhere from the age of 30 to 55 years old. The study also found that psychiatry was the profession with the fewest claims. Neurosurgery, obstetrics and gynaecology and orthopaedics had claim rates 7 to 12 times that of psychiatry.[45] There was no association between claims rate and a physician's site of training or type of degree.[46]

A physician who has adverse claims experience is more likely to be sued again and is also less likely to change their practice.[47]

Similarly, another study that analyzed malpractice claims found that the annual frequency of claims was higher among surgeons, obstetricians and gynaecologists and physicians in a group practice.[48] It also found that specialists who spent more time with patients were less likely to incur a claim.[49]

Patient demographics

If some typical demographics are associated with doctors who are more likely to be sued, then it seems reasonable that there may be some groups of patients who could be similarly identified demographically as being more likely to sue.

In the past, there has been a perception amongst doctors that patients from a poor socio-economic background are more likely to sue, as they need the money from compensatory payouts more than richer patients.[50,51] However, this does not take into account the money required by patients to initiate legal proceedings, which may be prohibitive for those at the poorer end of the spectrum.[52,53] This attitude also assumes that patients are primarily after money, which is often not the case.[54] Earlier analyses of the suing behaviour of patients looked at the claims filed by US Medicaid patients versus patients who paid another way, with contradictory results.[55,56,57] A case-control study from 1992 looked instead directly at socio-economic status and found that poor and uninsured patients were 80 percent less likely to sue for malpractice.[58]

Another underrepresented group when looking at malpractice claims seems to be the elderly.[59,60,61] This is somewhat surprising as the elderly have greater exposure to potential negligence.[62] This may be because the elderly have fewer expectations of their doctors. The elderly are more likely to see one doctor regularly, improving the doctor-patient relationship.[63] The younger population may provide more attractive clients to lawyers, as the size of an award may be substantially larger, given their extra life-expectancy. Some elderly people may also be incapable of recognizing that they have suffered a medical injury or received sub-standard care. Also, the elderly are unlikely to be earning an income.

The typical injured claimant from Medical Practice Study was a worker who was disabled by a medical injury and who faced large wage losses.[64]

Perceived gains of initiating suits

Doctors' understanding into why patients take legal action seems to be poor. Many feel that a diagnostic problem is the main reason that patients litigate.[65,66] Yet in none of the studies that asked patients directly about their reasons for suing was this identified as a major cause for litigation.[67,68]

A study of patients and relatives taking legal action in the UK identified four main reasons for litigation: concern with standards of care; so that the doctor would be made accountable for their error; financial compensation; and, the need for an explanation of what happened.[69] Other studies into why patients sue or complain have findings that tend to fit into one or another of these categories. [70,71]

Concern with the Standards of Care

Usually, litigants who fall into this category want to prevent similar incidents in the future.[72] They would like to know that lessons had been learnt from their experiences.[73,74] Few of these patients wanted compensation; more wanted the doctor to be punished.[75]

Accountability

These patients are often angry.[76,77] When asked for their reasons for suing, it is often to get revenge against their doctor.[78,79] A study that looked at medical malpractice claims following perinatal injuries also found that these parents were more likely to have a child that died and were more likely to complain that their physician would not hear their concerns. [80]   

Compensation

In the same study, 24 percent of parents volunteered that they initiated legal proceedings because they needed the money for long-term care.[81] Often when compensation was cited as the motivating factor to sue a doctor, there was the long-term care of a child or young adult involved that would involve heavy medical bills in the long-term [82,83].

Expectations

A patient may sue because their expectations are thwarted [84,85]. 20 percent of parents suing on behalf of their children after a perinatal injury claimed they decided to sue when they realized their child would never be normal [86]. Doctors may be unwilling to discuss all the possible risks associated with a procedure.[87] When expectations of patients are poorly met, it is often due to poor communication from their doctor.[88,89,90]

Explanation

The study of patients and relatives from the UK found that less than 15 percent of explanations were considered satisfactory and that the majority were felt to be unclear, inaccurate and lacking information. Explanations were given sympathetically in less than 40 percent of cases.[91] Other studies have similarly found that the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care.[92] As a result, many patients appear to be using the legal system in order to gain a thorough appreciation of the adverse event and its causes.[93,94] Patients also ring law firms when they feel that information has been withheld from them[95].

Reducing the number of malpractice suits

Doctors are human and it is foolish to assume that they will never make an error. A creative and vigorous approach to reducing errors that do occur would obviously be helpful.[96] However, it is clear that there are interpersonal factors in the doctor-patient relationship that could lead to a patient having an increased propensity to sue.[97, 98,99,100]

A number of opinions all offer similar advice to doctors to avoid being sued.[101,102,103,104] Patients require, and are entitled to, full explanations of their treatment. Understand that patients may not take in everything discussed about an adverse event in one sitting. Written information and arranging a time for a follow-up consultation may be necessary. It is important the patient feels that they are being treated in a sympathetic and courteous manner. [105]

A study that examined the psychological impact of surgical events found that patients were extremely unsatisfied with the explanations given about their accident. They perceived such explanations as lacking in information, unclear, inaccurate and felt that they were given unsympathetically. Poor explanations were found to be associated with higher levels of disturbing memories and poor adjustment.[106] If people do not adjust well after an adverse event has occurred, they are more likely to feel the need to initiate litigation.

It is also important that a patient has a clear understanding of the risks and benefits and the possible outcomes of treatment. The Tito report found that patients with a realistic perception of treatment are able to make more informed health care choices and are less likely to litigate if an adverse event does occur.[107] This is because the adverse event will be accepted as a risk that they were prepared to take when weighed against the possible benefits.

When an adverse event has occurred, often patients want an explanation and an apology.[108] However, doctors are often reluctant to provide an apology, fearing that this may be an admission of liability.[109] However, the Victorian Health Services Commissioner maintains that medical practitioners can express regret and acknowledge a person's grief and pain without admitting legal liability.[110]

Patients' approval of health care is related to issues like availability, cost and general quality. It is equally related to being treated with humanity, having confidence in the health care providers, the availability of information, and the handling of psycho-social problems, the continuity of care and outcome of care.[111] The point has also been made that "patients do not sue doctors they like." [112]

Conclusion

Patient perceptions of their care and treatment provide the major reason for initiating litigation, regardless of the true quality of care. Poor communication between patients and doctors is a recurring element of litigation.

FOOTNOTES

1 Taragin MI, Willett LR, Wilczek AP, Trout R, Carson JL, The influence of standard of care and severity of injury on the resolution of malpractice claims, Annals of Internal Medicine, 1992, Vol 117, pp780-784

2 Leape L.L, Brennan, TA, Laird, N., et al., The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II, New England Journal of Medicine,(1991), Vol 324; pp377-84

3 Localio, AR, Lawthers AG, Brennan, TA et al., Relation between malpractice claims and adverse events due to negligence: Harvard Study III, New England Journal of Medicine, 1991, Vol 325, pp 245-251

4 Leape L.L, Brennan, TA, Laird, N., et al., The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II, New England Journal of Medicine,(1991), Vol 324; pp377-84

5 Studdert, D., Thomas, E., Burstin H., et al. Negligent care and malpractice claiming behavior in Utah and Colarado, Medical Care, 2000, Vol 38, pp250-260

6 Localio, AR, Lawthers AG, Brennan, TA et al., Relation between malpractice claims and adverse events due to negligence: Harvard Study III, New England Journal of Medicine, 1991, Vol 325, pp 245-251

7 Leape L.L, Brennan, TA, Laird, N., et al., The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II, New England Journal of Medicine,(1991), Vol 324; pp377-84

8 Danzon PM, Medical malpractice: theory, evidence and public policy, Cambridge, Mass, Harvard University Press, 1985

9 Localio, AR, Lawthers AG, Brennan, TA et al., Relation between malpractice claims and adverse events due to negligence: Harvard Study III, New England Journal of Medicine, 1991, Vol 325, pp 245-251

10 Studdert, D., Thomas, E., Burstin H., et al. Negligent care and malpractice claiming behaviour in Utah and Colarado, Medical Care, 2000, Vol 38, pp250-260

11 Entman, S., Glass, C., Hickson, G., et al., The relationship between malpractice claims history and subsequent obstetric care, Journal of the American Medical Association,1994, Vol 272, pp 1588-1591

12 Resch-Hoeczke, A., Ofner H., Schima, W., and Imhof H., The civil law liability in radiology. An analysis of the administration of justice. (original article in German), Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 1995, Vol 162, pp 65-71

13 Hickson, G., Clayton, E., Entman, S. et al. Obstetricians' prior malpractice experience and patients' satisfaction with care, Journal of the American Medical Association,1994, Vol 272, pp1583-1587

14 Hickson, G., Clayton, E., Entman, S. et al. Obstetricians' prior malpractice experience and patients' satisfaction with care, Journal of the American Medical Association,1994, Vol 272, pp1583-1587

15 Health Services Commissioner Victoria Report, 1988

16 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

17 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370;

18 Lester, GW and Smith, SG, Listening and talking to patients: a remedy for malpractice suits, Western Journal of Medicine, 1993, Vol 158, pp268-272

19 Moore PJ, Adler NE, Robertson PA, Medical malpractice: the effect of doctor-patient relations and malpractice intentions, Western Journal of Medicine, 2000, Vol 173, pp244-50

20 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

21 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

22 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

23 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

24 Mangels, Informed consent: talk to your patients...or talk to your attorney, Indiana Medicine, 1991, Vol 84, pp410-411

25 Daniel AE, Burn RJ, Horarik S., Patients' complaints about medical practice, Medical Journal of Australia, 1999; Vol 170, pp598-602

26 Vogel J., Delgado, R., To tell the truth: physicians' duty to disclose medical mistakes, UCLA Law Review, 1980, Vol 28:52

27 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

28 Novack DH, Detering BJ, Arnold R, et al., Physicians' attitudes toward using deception to resolve difficult ethical problems, Journal of the American Medical Association, 1989, Vol 261, pp2980-2985

29 Mizrahi T, Managing medical mistakes: ideology, insularity and accountability among internists-in-training, Social Science Medicine, 1984, Vol 19 pp135-146

30 Witman, AB, Park, DM, Hardin, SB, How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting, Archives of Internal Medicine, 1996, Vol 156, pp2565-2569

31 Kachalia, A., Shojania KG, Hofer TP, Pitrowski, M, Saint S, Does full disclosure of medical errors affect malpractice liability? The jury is still out, Joint Commission Journal on Quality & Safety, 2003, Vol 29, pp503-511

32 Daniel AE, Burn RJ, Horarik S., Patients' complaints about medical practice, Medical Journal of Australia, 1999; Vol 170, pp598-602

33 Kachalia, A., Shojania KG, Hofer TP, Pitrowski, M, Saint S, Does full disclosure of medical errors affect malpractice liability? The jury is still out, Joint Commission Journal on Quality & Safety, 2003, Vol 29, pp503-511

34 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

35 Witman, AB, Park, DM, Hardin, SB, How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting, Archives of Internal Medicine, 1996, Vol 156, pp2565-2569

36 Kachalia, A., Shojania KG, Hofer TP, Pitrowski, M, Saint S, Does full disclosure of medical errors affect malpractice liability? The jury is still out, Joint Commission Journal on Quality & Safety, 2003, Vol 29, pp503-511

37 Zuckerman S, Medical Malpractice: claims, legal costs, and the practice of defensive medicine, Health Affairs (Millwood), 1984, Vol 3, pp128-133

38 Taragin MI, Wilczek, AP, Karns, ME, Trout, R, Carson, JL, Physician demographics and the risk of medical malpractice, 1992, Vol 93, pp 537-542

39 Adams EK, Zuckerman S., Variation in the growth and incidence of medical malpractice claims, Journal of Health Politics, Policy & Law, 1984, Vol 9, pp475-488

40 Taragin MI, Wilczek, AP, Karns, ME, Trout, R, Carson, JL, Physician demographics and the risk of medical malpractice, 1992, Vol 93, pp 537-542

41 Ferber, S and Sheridan B, Six cherished malpractice beliefs put to rest, Medical Economics, 1975, Vol 52, pp150-156

42 Adams EK, Zuckerman S., Variation in the growth and incidence of medical malpractice claims, Journal of Health Politics, Policy & Law, 1984, Vol 9, pp475-488

43 Taragin MI, Wilczek, AP, Karns, ME, Trout, R, Carson, JL, Physician demographics and the risk of medical malpractice, 1992, Vol 93, pp 537-542

44 Taragin MI, Wilczek, AP, Karns, ME, Trout, R, Carson, JL, Physician demographics and the risk of medical malpractice, 1992, Vol 93, pp 537-542

45 Taragin MI, Wilczek, AP, Karns, ME, Trout, R, Carson, JL, Physician demographics and the risk of medical malpractice, 1992, Vol 93, pp 537-542

46 Taragin MI, Wilczek, AP, Karns, ME, Trout, R, Carson, JL, Physician demographics and the risk of medical malpractice, 1992, Vol 93, pp 537-542

47 Sloan FA, Mergenhagen, PM, Burfield WB, Bovbjerg RR, Hassan M, Medical malpractice experience of physicians. Predictable or haphazard?, The Journal of the American Medical Association, 1989, Vol 262, pp3291-3297

48 Adams EK, Zuckerman S., Variation in the growth and incidence of medical malpractice claims, Journal of Health Politics, Policy & Law, 1984, Vol 9, pp475-488

49 Adams EK, Zuckerman S., Variation in the growth and incidence of medical malpractice claims, Journal of Health Politics, Policy & Law, 1984, Vol 9, pp475-488

50 Studdert, D., Thomas, E., Burstin H., et al. Negligent care and malpractice claiming behavior in Utah and Colarado, Medical Care, 2000, Vol 38, pp250-260

51 Burstin, HR, Johnson WG, Lipsitz SR, Brennan TA, Do the poor sue more? A case-control study of malpractice claims and socioeconomic status, The Journal of the American Medical Association, 1993, Vol 270, pp 1697-1701

52 Burstin, HR, Johnson WG, Lipsitz SR, Brennan TA, Do the poor sue more? A case-control study of malpractice claims and socioeconomic status, The Journal of the American Medical Association, 1993, Vol 270, pp 1697-1701

53 Studdert, D., Thomas, E., Burstin H., et al. Negligent care and malpractice claiming behavior in Utah and Colarado, Medical Care, 2000, Vol 38, pp250-260

54 Daniel AE, Burn RJ, Horarik S., Patients' complaints about medical practice, Medical Journal of Australia, 1999; Vol 170, pp598-602

55 Opinion Research Corporation, Hospital survey on obstetric claim frequency by patient payer category, Washington DC, American College of Obstetricians and Gynaecologists, 1998

56 Mussman, MG, Zawistowich L., Weisman CS, Malitz FE, Morlock LL, Medical malpractice claims filed by Medicaid and non-Medicaid recipients in Maryland, Journal of the American Medical Association, 1991, Vol 265, pp2992-2994

57 US Congress, Office of Technology Assessment, Do Medicaid and Medicare patients sue physicians more often than other patients?, 1992, Washington DC, Office of Technology Assessment

58 Burstin, HR, Johnson WG, Lipsitz SR, Brennan TA, Do the poor sue more? A case-control study of malpractice claims and socioeconomic status, The Journal of the American Medical Association, 1993, Vol 270, pp 1697-1701

59 Burstin, HR, Johnson WG, Lipsitz SR, Brennan TA, Do the poor sue more? A case-control study of malpractice claims and socioeconomic status, The Journal of the American Medical Association, 1993, Vol 270, pp 1697-1701

60 Studdert, D., Thomas, E., Burstin H., et al. Negligent care and malpractice claiming behavior in Utah and Colorado, Medical Care, 2000, Vol 38, pp250-260

61 Sager M, Voecks S, Drinka P, Langerr, E, Grimstad, P., Do the elderly sue physicians?, Archives of Internal Medicine, 1990, Vol 150, pp1091-3

62 Sager M, Voecks S, Drinka P, Langerr, E, Grimstad, P., Do the elderly sue physicians?, Archives of Internal Medicine, 1990, Vol 150, pp1091-3

63 Burstin, HR, Johnson WG, Lipsitz SR, Brennan TA, Do the poor sue more? A case-control study of malpractice claims and socioeconomic status, The Journal of the American Medical Association, 1993, Vol 270, pp 1697-1701

64 Burstin, HR, Johnson WG, Lipsitz SR, Brennan TA, Economic analysis of medical malpractice: final report, 1993, Princeton, NJ, Robert Wood Johnston Foundation

65 Roberts RG, Seven reasons family doctors get sued and how to reduce your risk, Family Practice Management, March 2003, pp29-34

66 Langlands AO, Gebski V, Hirsch D, Tattersall MH, Delay in the clinical diagnosis of breast cancer: estimating its effect on prognosis, with particular reference to medical litigation, Breast, 2002, Vol 11, pp 386-393

67 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

68 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

69 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

70 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

71 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

72 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

73 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

74 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

75 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

76 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

77 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

78 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

79 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

80 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

81 Huycke LI, Huycke MM, Characteristics of potential plaintiffs in malpractice litigation, The Annals of Internal Medicine, 1994, Vol 120, pp792-8.

82 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

83 Huycke LI, Huycke MM, Characteristics of potential plaintiffs in malpractice litigation, The Annals of Internal Medicine, 1994, Vol 120, pp792-8.

84 Nisselle, P., Recipe for a poor writ: poor rapport + unmet expectations + big bill = a writ, Australian Family Physician, 1993, Vol 26, pp824-826

85 Moyle S, Health care practice and the minimization of patient medical litigation, Australian Health Review, 1999, Vol 22, pp44-55

86 Huycke LI, Huycke MM, Characteristics of potential plaintiffs in malpractice litigation, The Annals of Internal Medicine, 1994, Vol 120, pp792-8.

87 Moyle S, Health care practice and the minimization of patient medical litigation, Australian Health Review, 1999, Vol 22, pp44-55

88 Nisselle, P., Recipe for a poor writ: poor rapport + unmet expectations + big bill = a writ, Australian Family Physician, 1993, Vol 26, pp824-826

89 Moyle S, Health care practice and the minimization of patient medical litigation, Australian Health Review, 1999, Vol 22, pp44-55

90 Huycke LI, Huycke MM, Characteristics of potential plaintiffs in malpractice litigation, The Annals of Internal Medicine, 1994, Vol 120, pp792-8.

91 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

92 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

93 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

94 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

95 Huycke LI, Huycke MM, Characteristics of potential plaintiffs in malpractice litigation, The Annals of Internal Medicine, 1994, Vol 120, pp792-8.

96 Leape L, Errors in medicine, The Journal of the American Medical Association, 1994, Vol 272, pp 1851-1857

97 Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor-patient relationship and malpractice, Archives of Internal Medicine, 1994, Vol 54, pp1365-1370

98 Hickson, GB, Clayton EW, Githens PB, Sloan FA, Factors that prompted families to file medical malpractice claims following perinatal injuries, The Journal of the American Medical Association, 1992, Vol 267, pp1359- 1363

99 Nisselle, P., Recipe for a poor writ: poor rapport + unmet expectations + big bill = a writ, Australian Family Physician, 1993, Vol 26, pp824-826

100 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

101 Oppenberg AA, Adverse outcomes: what do you do?, Californian Physician, 1992, Vol 9, 44

102Applegate WB, Physician management of patient with adverse outcomes, Annals of Internal Medicine, 1986, Vol 146, pp2249-2252

103 Royal Australian College of Physicians, Guidelines for the Medical Profession on Informed Consent, Fellowship Affairs, 1998, Royal Australian College of Physicians

104 Health Care Committee of the NHMRC, General Guidelines for Medical Practitioners on Providing Information to Patients, 1994

105 Health Care Committee of the NHMRC, General Guidelines for Medical Practitioners on Providing Information to Patients, 1994

106 Vincent CA, Pincus T, Scurr JH, Patients' experience of surgical accidents, Qualitative Health Care. 1993, Vol 2, pp77-82

107 Moyle S, Health care practice and the minimization of patient medical litigation, Australian Health Review, 1999, Vol 22, pp44-55

108 Vincent C, Young M, Phillips A., Why do people sue doctors? A study of patients and relatives taking legal action, Lancet, 1994, Vol 25, pp1609-13

109 Steelos L, Adamson C, Redefining NHS complaint handling- the real challenge, International Journal of Healthcare Quality Assurance, Vol 7, pp26-31

110 Victorian Health Services Commissioner, 1998, BLEC Conference, Paper presented at the Medico-Legal Conference, Victoria, March 1998

111 Hall JA, Dornan MC, What patients like about their medical care and often they are asked: a matter of analysis of the satisfaction literature, Social Science and Medicine, 1998, Vol 27, pp 235-239

112 Batchelor C, Owens DJ, Read M, Bloor M, Patient satisfaction studies: methodology, management and consumer evaluation, International Journal of Healthcare Quality Assurance, Vol 7, pp22-30

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