Association between physician explanatory behaviors and substandard care in adjudicated cases in Japan

Figures & data

Table 3 Comparison of physicians’ explanatory behaviors by period of decision

	Period of court decisions			Pvalue^d
	1979–1989 (n = 122)^a	1990–1999 (n = 98)^b	2000–2008 (n = 146)^c
1. Purpose of physician’s explanation: obtaining patient’s consent/other	53 (51.5)/50 (48.5)	60 (71.4)/24 (28.6)	100 (76.3)/31 (23.7)	0.000
2. Provision of an explanation by physician: no explanation/other	35 (34.0)/68 (66.0)	14 (16.7)/70 (83.3)	12 (9.2)/119 (90.8)	0.000
3. Timing of physician’s explanation: prior to treatment or surgery/after treatment or surgery	50 (74.6)/17 (25.4)	54 (77.1)/16 (22.9)	99 (82.5)/21 (17.5)	0.406
4. Recipient of physician’s explanation: patient, patient and family/family only	39 (57.4)/29 (42.6)	53 (75.7)/17 (24.3)	100 (83.3)/20 (16.7)	0.000*
5. Manner of physician’s explanation to the patient: oral only/oral and other methods	36 (94.7)/2 (5.3)	41 (77.4)/12 (22.6)	67 (67.7)/32 (32.3)	0.004*
6. Manner of physician’s explanation to family: oral only/oral and other methods	33 (84.6)/6 (15.4)	32 (80.0)/8 (20.0)	64 (81.0)/15 (19.0)	0.851
7. Level of physician’s explanation to the patient: relevant and specific to treatment/not sufficiently relevant or specific to treatment	11 (32.4)/23 (67.6)	15 (28.8)/37 (71.2)	34 (35.4)/62 (64.6)	0.717
8. Level of physician’s explanation to family: relevant and specific to treatment/not sufficiently relevant or specific to treatment	10 (35.7)/18 (64.3)	12 (32.4)/25 (67.6)	27 (38.6)/43 (61.4)	0.819
9. Place in which physician’s explanation was provided: inpatient ward/outpatient clinic	57 (55.3)/46 (44.7)	48 (57.1)/36 (42.9)	68 (51.9)/63 (48.1)	0.734
10. Content of physician’s explanation: related to surgery or treatment/other	34 (27.9)/88 (72.1)	40 (40.8)/58 (59.2)	58 (39.7)/88 (60.3)	0.068
11. Frequency of physician’s explanation: once/twice or more	37 (55.2)/30 (44.8)	27 (40.3)/40 (59.7)	45 (37.8)/74 (62.2)	0.061
12. Patient’s consent to treatment: yes/no	34 (91.9)/3 (8.1)	40 (90.9)/4 (9.1)	77 (89.5)/9 (10.5)	0.913
13. Family’s consent to treatment: yes/no	23 (88.5)/3 (11.5)	31 (88.6)/4 (11.4)	59 (95.2)/3 (4.8)	0.404
14. Written consent by patient: yes/no	3 (23.1)/10 (76.9)	9 (47.4)/10 (52.6)	33 (61.1)/21 (38.9)	0.038*
15. Written consent by family: yes/no	2 (18.2)/9 (81.8)	11 (57.9)/8 (42.1)	24 (61.5)/15 (38.5)	0.030*
16. Physician’s explanation prior to the day of surgery or treatment: yes/no	15 (31.3)/33 (68.8)	7 (13.5)/45 (86.5)	19 (20.2)/73 (79.8)	0.092

Notes:

* P < 0.05.

a Numbers all items except for 10 do not add up to 122 due to missing values;

b numbers all items except for 10 do not add up to 98 due to missing values;

c numbers all items except for 10 do not add up to 146 due to missing values;

d χ² test or G test.

Table 2 Comparison of patient and physician characteristics by period of decision

Items	Period			P^d
	1979–1989 (n = 122)^a	1990–1999 (n = 98)^b	2000–2008 (n = 146)^c
Patients
1. Patient age (years)	22.07 ± 22.30	40.17 ± 21.73	47.43 ± 21.70	0.000*
2. Male/female	65 (54.6)/54 (45.4)	51 (53.1)/45 (46.9)	69 (47.9)/75 (52.1)	0.520
3. Type of treatment: elective or not urgently necessary/other^e	7 (5.7)/115 (94.3)	9 (9.2)/89 (90.8)	17 (11.6)/129 (88.4)	0.228
4. Severity of injury: death/other^f	37 (30.3)/85 (69.7)	46 (46.9)/52 (53.1)	77 (52.7)/69 (47.3)	0.001*
Physicians
1. Department in which patients were treated: surgical/other^g	43 (35.2)/79 (64.8)	46 (46.9)/52 (53.1)	60 (41.1)/86 (58.9)	0.213
2. Type of medical facility, clinic/hospital	29 (24.0)/92 (76.0)	20 (20.4)/78 (79.6)	30 (20.7)/115 (79.3)	0.760
3. Number of physicians, 1/2 or more	69 (56.6)/53 (43.4)	51 (52.0)/47 (48.0)	75 (51.7)/70 (48.3)	0.696
4. Medical standard: standard care/not standard care	87 (71.9)/34 (28.1)	84 (85.7)/14 (14.3)	131 (91.0)/13 (9.0)	0.000*
5. Physician’s apology: presence/absence	1 (0.8)/117 (99.2)	1 (1.0)/95 (99.0)	10 (6.8)/136 (93.2)	0.008*
6. Physician’s status as a specialist in the type of care: yes/other (no or unknown)	94 (77.0)/28 (23.0)	86 (87.8)/12 (12.4)	136 (93.2)/10 (6.8)	0.002*
Medical litigation
1. Introduction of evidence by medical expert witness (yes/no)	24 (19.7)/98 (80.3)	36 (36.7)/62 (63.3)	66 (45.2)/80 (54.8)	0.000*
2. Type of plaintiff: patient, patient and family/family only	86 (70.5)/36 (29.5)	52 (53.1)/46 (46.9)	67 (45.9)/79 (54.1)	0.000*
3. Number of issues: 0–3/4 or more	56 (46.3)/65 (53.7)	62 (63.3)/36 (36.7)	87 (59.6)/59 (40.4)	0.023*
4. Ratio of damages awarded to damages sought	12.59 ± 22.71	23.20 ± 29.56	37.73 ± 68.27	0.000*
5. Damages awarded (mean ± SD, yen)	3,278,991 ± 102,107	5,771,796 ± 819,806	8,785,617 ± 103,107	0.000*

Notes:

* P < 0.05.

a Numbers in several items (“Patients” 2, “Physicians” 2, 3, 4, and 5, and “Medical litigation” 3) do not add up to 122 due to missing values;

b numbers in several items (“Patients” 2, “Physicians” 5) do not add up to 98 due to missing values;

c numbers in several items (“Patients” 2, “Physicians” 2, 3, and 4) do not add up to 146 due to missing values;

d χ² test (or G test) or one-way analysis of variance;

e “Other” includes “treatment is urgently necessary” and “other”;

f “Other” includes temporary or permanent injury;

g “Other” includes internal medicine, pediatrics, obstetrics, ophthalmology, otolaryngology, dermatology, dentistry, urology, and others.

Table 1 Number of cases by type of physician liability and decision year

	Period of decisions
	1979–1989 (n = 122)	1990–1999 (n = 98)	2000–2008 (n = 146)
1. Court decided in favor of physician’s legal liability (%)	42 (34.4%)	61 (62.2%)	114 (78.1%)
2. Court decision acknowledged physician’s fault with respect to medical judgment or technical procedures (%)	31 (23.0%)	35 (25.9%)	69 (51.1%)
3. Court decision acknowledged breach with respect to physician’s duty to explain (%)	23 (15.9%)	41 (28.3%)	81 (55.9%)
4. Court decision acknowledged physician’s fault with respect to both medical judgment or technical procedures and breach of duty to explain (%)	12 (18.8%)	15 (23.4%)	37 (57.8%)

Table 4 Changes in physician’s explanatory behaviors related to court decisions by period of decision

	1979–1989			1990–1999			2000–2008
	Breach: Yes	Breach: No	P^a	Breach: Yes	Breach: No	P^a	Breach: Yes	Breach: No	P^a
1. Purpose of physician’s explanation (to obtain patient’s consent)	8 (34.8%)	45 (56.3%)	0.07	26 (61.9%)	34 (81.0%)	0.05	57 (71.3%)	43 (84.3%)	0.09
2. Provision of an explanation by physician (no explanation)	10 (43.5%)	25 (31.3%)	0.28	7 (16.7%)	7 (16.7%)	1.00	9 (11.3%)	3 (6.0%)	0.24
3. Timing of physician’s explanation (prior to treatment or surgery)	8 (61.5%)	42 (77.8%)	0.19	23 (65.7%)	31 (88.6%)	0.02*	54 (76.1%)	45 (91.8%)	0.02*
4. Recipient of physician’s explanation (patient, patient and family)	8 (61.5%)	31 (56.4%)	0.73	26 (74.3%)	27 (77.1%)	0.78	56 (78.9%)	44 (89.8%)	0.09
5. Manner of physician’s explanation to the patient (oral only)	8 (100%)	28 (93.3%)	0.62	20 (76.9%)	21 (77.8%)	0.94	42 (75.0%)	25 (58.1%)	0.07
6. Manner of physician’s explanation to family (oral only)	5 (71.4%)	28 (87.5%)	0.29	17 (85.0%)	15 (75.6%)	0.35	38 (88.4%)	26 (72.2%)	0.06
7. Level of physician’s explanation to the patient (relevant and specific)	0 (0%)	11 (42.3%)	0.03*	0 (0%)	15 (57.7%)	0.00*	0 (0%)	34 (87.2%)	0.00*
8. Level of physician’s explanation to the family (relevant and specific)	0 (0%)	10 (45.5%)	0.04*	0 (0%)	12 (66.7%)	0.00*	1 (2.4%)	26 (89.7%)	0.00*
9. Place in which physician’s explanation was provided (inpatient ward)	10 (43.5%)	47 (58.8%)	0.19	20 (47.6%)	28 (66.7%)	0.08	32 (40.0%)	36 (70.6%)	0.00*
10. Content of physician’s explanation (related to surgery and treatment)	4 (16.7%)	23 (28.7%)	0.18	16 (38.1%)	16 (38.1%)	1.00	26 (32.5%)	25 (48.1%)	0.07
11. Frequency of physician’s explanation (once)	7 (53.8%)	30 (55.6%)	0.91	14 (41.2%)	13 (40.6%)	0.96	28 (40.0%)	16 (34.0%)	0.46
12. Patient’s consent to treatment (yes)	4 (57.1%)	30 (100%)	0.01*	18 (85.7%)	22 (95.7%)	0.27	39 (84.8%)	37 (94.9%)	0.12
13. Family’s consent to treatment (yes)	3 (100%)	20 (87.0%)	0.68	14 (93.3%)	17 (85.0%)	0.42	28 (93.3%)	30 (96.8%)	0.49
14. Written consent by patient (yes)	0 (0%)	3 (37.5%)	0.20	5 (50.0%)	4 (44.4%)	0.59	17 (51.5%)	15 (75.0%)	0.08
15. Written consent by family (yes)	1 (33.3%)	1 (12.5%)	0.49	4 (50.0%)	7 (63.6%)	0.45	10 (50.0%)	13 (72.2%)	0.14
16. Physician’s explanation prior to the day of surgery or treatment (yes)	3 (42.9%)	30 (73.2%)	0.13	19 (76.0%)	26 (96.3%)	0.04*	35 (70.0%)	38 (90.5%)	0.01*

Notes:

* P < 0.05.

a χ² test or Fisher’s Exact test. Note: “Breach: Yes” indicates court acknowledgement of breach in the physician’s duty to explain; “Breach: No” indicates no court acknowledgement of breach in the physician’s duty to explain.