• William O Cooper, Oscar Guillamondegui, O Joe Hines, C Scott Hultman, Rachel R Kelz, Perry Shen, David A Spain, John F Sweeney, Ilene N Moore, Joseph Hopkins, Ira R Horowitz, Russell M Howerton, J Wayne Meredith, Nathan O Spell, Patricia Sullivan, Henry J Domenico, James W Pichert, Thomas F Catron, Lynn E Webb, Roger R Dmochowski, Jan Karrass, and Gerald B Hickson.
• Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee.
• JAMA Surg. 2017 Jun 1; 152 (6): 522-529.

ImportanceUnsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves.ObjectiveTo examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations.Design, Setting, And ParticipantsThis retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016.ExposuresUnsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation.Main Outcomes And MeasuresPostoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest.ResultsAmong the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile.Conclusions And RelevancePatients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

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