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Nov 3 2014

Medical Board complaints against physicians due to communication: Analysis of NC Medical Board Data,

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ABSTRACT: Anecdotal evidence suggests that communication issues are one of the primary reasons for physician complaints, but quantitative studies have yet to examine this assertion. The North Carolina Medical Board’s Complaint Department maintains data on physician complaints and categorizes each complaint based on its primary cause. Using data from 2002–2012, our research focused on complaints against physicians licensed by the North Carolina board to determine the extent to which communication issues contribute to complaints against physicians. An analysis of this data reveals that physician complaints based on communication issues are consistently the most prevalent reason for complaints against physicians in the state of North Carolina. In addition, communication-based complaints account for more than one in five complaints made against North Carolina physicians. These results are discussed in light of their implications for the field of medicine as it seeks to improve patient care.

Introduction
In 2012, the 69 state and territorial medical boards of the United States took 9,219 actions against the licenses of 4,479
physicians.(1) The vast majority of these actions originated as a complaint reported by patients or their family members. The literature addressing the bases for patient complaints leading to disciplinary actions by state medical boards is minimal as the focus to date has been on state-specific and aggregate actions. (2)

Several studies, however, have examined communication as a factor in negative outcomes. One study found “significant
differences” in the communication behaviors of primary care physicians that aligned with malpractice claims history. (3) A study of obstetricians showed that those physicians sued more
often were cited for the “interpersonal care” they provided.(4) Similarly, one study found that scores on the communication and clinical decision-making components of Canada’s licensing examination were predictive of later complaints to that country’s medical regulatory authorities.(5)

The importance of communication as a core competency critical to physicians’ effectiveness in practice has been affirmed across the continuum of medical education by accrediting, certifying and licensing bodies. Communication and interpersonal skills have been identified as a critical competency for physicians in graduate medical education, (6,7) specialty board certification, (8,9) and since 2004, for inclusion in the examinations accepted for medical licensure in this country (United States Medical Licensing Examination and Comprehensive Osteopathic Medical Licensing Examination).

Conversations with various executive directors and members of state medical boards on this subject routinely include personal observations that communication issues are a factor in many of the complaints received by state medical boards each year. Our objective is to begin moving the discussion beyond anecdotal evidence by examining complaints against physicians received
by the North Carolina Medical Board since the year 2002, and the extent to which communication issues are identified as a reason for the complaint.

Methodology
The North Carolina Medical Board’s Complaint Department maintains records on complaints filed against physicians licensed in the state. The department's vital to the North Carolina Medical Board’s mission to protect the public through physician discipline, as complaints submitted by patients and/or family members are the primary means by which the board learns about physician impropriety. In addition to patient complaints, the department also receives complaints that originate from other sources, including disciplinary actions from other states. Complaints are received and evaluated by staff within the department, who review each case and determine whether the complaint relates to a violation of board policy or state law, thereby warranting a formal investigation and possible disciplinary action against the physician. According to state law, individuals who file complaints against physicians licensed in North Carolina are entitled to learn the outcome of their complaint. Thus, decisions to open an investigation (or a determination not to) are communicated to the party making the original complaint.

The North Carolina Medical Board began compiling, categorizing, and maintaining its current database of information about complaints towards physicians in 1978, and by the late 1980s, the board began to accumulate significant data that might be useful for longitudinal analysis. Complaints have steadily risen since the turn of the century, an increase that can be partly attributed to the board beginning to accept complaints by email in 2006. The North Carolina Medical Board categorizes complaints into nearly 100 categories, reporting the primary reason, as well as up to four secondary reasons for the complaint. Using data from 2002 to 2012, our research focuses on complaints against physicians licensed by the North Carolina Medical Board, to determine the extent to which communication issues contribute to complaints against physicians.

Results
An examination of the data revealed communication issues, out-of-state actions and quality of care are the top three reasons for complaints against physicians licensed in
North Carolina. As demonstrated in Figure 1, communication issues have frequently been the top reason for complaints against physicians. In the mid 2000s, out-of-state actions* and quality-of-care complaints surpassed communication complaints as the most prevalent reason for complaint, but from 2008 to 2012 communication issues were again the top reason for physician complaints. Between 2010 and 2012, more than 500 complaints made to the North Carolina Medical Board involved communications with the physician as the primary reason for the complaint.

Communication issues are also the top reason for complaints against physicians when examining both primary and secondary reasons. Since 2008, communication issues have been the top reason for physician complaints, being a primary or secondary reason for more than 800 physician complaints in 2012. Communication issues also represent a sizeable proportion of the total number of complaints made against physicians each year in North Carolina. Since 2008, more than one in five complaints made to the North Carolina Medical Board were related to communication issues. It should also be noted that the prevalence of communication-based complaints may even be understated, as communication may have also played a role in complaints that are categorized as out-of-state actions.

The nature of the communication complaints against physicians varied markedly. Frequently cited reasons included the following: failure by the physician to consider the patient’s unique intellectual or cultural background; failure of the physician to maintain an appropriate level of professionalism when confronted with a difficult or contentious patient; lack of timely follow-up communication with patients about abnormal laboratory studies; and the insufficient attention to properly communicating appropriate details of the physician’s plan of care or treatment decisions.

Discussion
This analysis suggests that communication issues may be one of the most prevalent reasons for complaints against physicians to state medical boards. Communication skills are vital for physicians to effectively provide patient care, and poor communication skills are tied to negative outcomes such as malpractice claims. (3) In addition, a comprehensive analysis of studies examining the effects of physician-patient communication found a strong relationship to patient outcomes, (10) while another meta-analysis revealed that communication is highly correlated with patient adherence to treatment.(11)

Medical schools, specialty boards, and assessment organizations such as the National Board of Medical Examiners and the National Board of Osteopathic Medical Examiners recognize the importance of communication skills to the successful practice of medicine, as they require physicians to demonstrate competency in clinical skills such as communication. This paper lends further support to the idea that clinical skills such as communication are vital to effective medical practice, perhaps suggesting that healthcare entities should focus on physician communication skills as they seek to improve patient care and decrease patient complaints.

*The North Carolina Medical Board resolved a backlog of formal out-of-state actions between 2003 and 2004, resulting in a temporary spike in complaints during that time frame.

References
1. Federation of State Medical Boards. 2014.
2. Federation of State Medical Boards. Summary of 2011 Board Actions. www.fsmb.org/pdf/2011-summary-ofboard-actions.pdf. Accessed February 24, 2014.
3. Levinson, W, Roter, DL Mullooly, JP, et. al, “Physician-Patient Communication: The Relationship with Malpractice Claims Among Primary Care Physicians and Surgeons,” JAMA 1997;277(7);553-557.
4. Hickson, GB, Clayton, EW, Entman, SS, “Obstetricians’ Prior Malpractice Experience and Patients’ Satisfaction with Care,” JAMA 1994; 272(20):1583-87.
5. Tamblyn, R, Abrahamowicz, M, Dauphinee, D, “Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities,” JAMA 2007;
298(9):993-1001.
6. Sullivan, G, Simpson, D, et.al., “A Milestone in the Milestones Movement: the JGME Milestones, Journal of Graduate Medical Education March 2013 supplement, 1-4.
7. Tunanidas, AG, Burkhart, DN, “American Osteopathic Association Commitment to Quality and Lifelong Learning,” JAOA September 2005; 105(9):404-407.
8. American Board of Medical Specialties, “MOC Competencies and Criteria,” accessed at www.abms.org/maintenance_of_certification/MOC_competencies.aspx on December 4, 2013.
9. Journal of the American Osteopathic Association, “Osteopathic Specialty Board Certification,” accessed at www.jaoa.org/content/111/4/280.full.pdf on December 4, 2013
10. Canadian Medical Association Journal, “Effective Physician-Patient Communication and Health Outcomes: A Review,” accessed at www.ncbi.nlm.nih.gov/pmc/articles/ PMC1337906/
pdf/cmaj00069-0061.pdf on June 3, 2014.
11. Medical Care, “Physician Communication and Patient Adherence to Treatment: A Meta-analysis,” accessed at www.ncbi.nlm.nih.gov/pmc/articles/PMC2728700/ on June 3, 2014.

About the Authors
Phil Davignon, PhD, is Senior Research Analyst, Research and Data Integration, Federation of State Medical Boards.
Aaron Young, PhD, is Assistant Vice President, Research and Data Integration, Federation of State Medical Boards.
David Johnson, MA, is Senior Vice President, Assessment Services, Federation of State Medical Boards.

Acknowledgements
The authors wish to thank Scott Kirby, MD, Medical Director at the North Carolina Medical Board, and Hari Gupta, Director of Operations, for their contributions to this research project. Dr. Kirby contributed to the authors’ understanding of the medical board’s structure and the administrative protocols for capturing complaints. Mr. Gupta provided the data for this study. Clinical skills such as communication are vital to effective medical practice, perhaps suggesting that healthcare entities should focus on physician communication skills as they seek to improve patient care and decrease patient complaints.

This article is reprinted with permission. It originally appeared in
Volume 100, Number 2, 2014 of the Journal of Medical Regulation.


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