Friday, September 11, 2009

How's Your Beside Manner?

In his book, Blink, Malcolm Gladwell discusses the differences between doctors who get sued for malpractice with those who are not sued. Following is an excerpt from the book:

Believe it or not, the risk of being sued for malpractice has very little to do with how many mistakes a doctor makes. Analyses of malpractice lawsuits show that there are highly skilled doctors who get sued a lot and doctors who make lots of mistakes and never get sued. At the same time, the overwhelming number of people who suffer an injury due to the negligence of a doctor never file a malpractice suit at all. In other words, patients don't file lawsuits because they've been harmed by shoddy medical care. Patients file lawsuits because they've been harmed by shoddy medical care and something else happens to them.

What is that something else? It's how they were treated, on a personal level, by their doctor. What comes up again and again in malpractice cases is that patients say they were rushed or ignored or treated poorly. "People just don't sue doctors they like," is how Alice Burkin, a leading medical malpractice lawyer, puts it. "In all the years I've been in this business, I've never had a potential client walk in and say, 'I really like this doctor, and I feel terrible about doing it, but I want to sue him.' We've had people come in saying they want to sue some specialist, and we'll say, 'We don't think that doctor was negligent. We think it's your primary care doctor who was at fault.' And the client will say, 'I don't care what she did. I love her, and I'm not suing her.'"

Burkin once had a client who had a breast tumor that wasn't spotted until it had metastasized, and she wanted to sue her internist for the delayed diagnosis. In fact, it was her radiologist who was potentially at fault. But the client was adamant. She wanted to sue the internist. "In our first meeting, she told me she hated this doctor because she never took the time to talk to her and never asked about her other symptoms," Burkin said. "'She never looked at me as a whole person,' the patient told us.. .. When a patient has a bad medical result, the doctor has to take the time to explain what happened, and to answer the patient's questions—to treat him like a human being. The doctors who don't are the ones who get sued." It isn't necessary, then, to know much about how a surgeon operates in order to know his likelihood of being sued. What you need to understand is the relationship between that doctor and his patients.

Recently the medical researcher Wendy Levinson recorded hundreds of conversations between a group of physicians and their patients. Roughly half of the doctors had never been sued. The other half had been sued at least twice, and Levinson found that just on the basis of those conversations, she could find clear differences between the two groups. The surgeons who had never been sued spent more than three minutes longer with each patient than those who had been sued did (18.3 minutes versus 15 minutes). They were more likely to make "orienting" comments, such as "First I'll examine you, and then we will talk the problem over" or "I will leave time for your questions"—which help patients get a sense of what the visit is supposed to accomplish and when they ought to ask questions. They were more likely to engage in active listening, saying such things as "Go on, tell me more about that," and they were far more likely to laugh and be funny during the visit. Interestingly, there was no difference in the amount or quality of information they gave their patients; they didn't provide more details about medication or the patient's condition. The difference was entirely in how they talked to their patients.

It's possible, in fact, to take this analysis even further. The psychologist Nalini Ambady listened to Levinson's tapes, zeroing in on the conversations that had been recorded between just surgeons and their patients. For each surgeon, she picked two patient conversations. Then, from each conversation, she selected two ten-second clips of the doctor talking, so her slice was a total of forty seconds. Finally, she "content-filtered" the slices, which means she removed the high-frequency sounds from speech that enable us to recognize individual words. What's left after content-filtering is a kind of garble that preserves intonation, pitch, and rhythm but erases content. Using that slice—and that slice alone—Ambady did a Gottman-style analysis. She had judges rate the slices of garble for such qualities as warmth, hostility, dominance, and anxiousness, and she found that by using only those ratings, she could predict which surgeons got sued and which ones didn't.

Ambady says that she and her colleagues were "totally stunned by the results," and it's not hard to understand why. The judges knew nothing about the skill level of the surgeons. They didn't know how experienced they were, what kind of training they had, or what kind of procedures they tended to do. They didn't even know what the doctors were saying to their patients. All they were using for their prediction was their analysis of the surgeon's tone of voice. In fact, it was even more basic than that: if the surgeon's voice was judged to sound dominant, the surgeon tended to be in the sued group. If the voice sounded less dominant and more concerned, the surgeon tended to be in the non-sued group. Could there be a thinner slice? Malpractice sounds like one of those infinitely complicated and multidimensional problems. But in the end it comes down to a matter of respect, and the simplest way that respect is communicated is through tone of voice, and the most corrosive tone of voice that a doctor can assume is a dominant tone. Did Ambady need to sample the entire history of a patient and doctor to pick up on that tone? No, because a medical consultation is a lot like one of Gottman's conflict discussions or a student's dorm room. It's one of those situations where the signature comes through loud and clear.

Re-read the passage above and switch the term, doctor, with technician or plumber or carpet cleaner or electrician or any other term you use for field service. Change malpractice with complaints to friends and neighbors, to the state contractor licensing board, to the district attorney, or to the state attorney general, or poor ratings on Google or Yelp.

The implication is that you can reduce complaints about your field service personnel by...

  • Slowing down (and not even slowing down much).

  • Removing anxiety by informing customers what you will do in advance, pre-framing the call (e.g., "First, relax. While I need to troubleshoot, I'm sure this isn't anything we haven't handled before. I'll get you taken care of. Here's how I'm going to proceed. I'm going take a look at the problem you reported to make sure it's the real problem and not a symptom of something else. This is likely going to require me to check this location and that location. When I finish, I'll report my findings to you and answer any questions. After you're satisfied with the work to be performed and authorize me to proceed, I'm going to make the necessary repairs, collect payment, and be on my way and out of your hair. Does this sound acceptable to you?")

  • Listening to the customer with empathy and encouraging the customer to share information.

  • Assuming an attitude and a posture of service (i.e., lose all defensive arrogance).

In health care and home care, good technical skills are not enough. They must be complmented by good interpersonal skills. In fact, patients and customers will forgive and explain away technical screw ups when the interpersonal skills are strong. There is little forgiveness when the interpersonal skills are lacking.

Every service call has two components. One is the problem that must be repaired. The second is the customer who must be attended to and reassured. With doctors, we call this "beside manner."

How's yours?


  1. Amazing what 3 minutes can make. That is the part I will remember.

  2. Yeah, I found that fascinating too.

  3. I like your thoughts. Can you send me a link to your other posts?

    Justin Davis

    Legal Disclaimer: Author does not represent any legal position of Lightspeed Systems Inc. and is the author's opinion only. Lightspeed Systems provides internet filter services to K-12 schools and institutions

  4. Justin,

    Thanks for the comments. Simply visit to read more. You can also find several hundred other magazine and trade journal articles around the Internet if you'll simply Google my name.