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BACKGROUND. Physicians who have been sued multiple times for malpractice are assumed to be less competent than those who have never been sued. However, there is a lack of data to support this assumption. Competence includes both knowledge and performance, and there are theoretical reasons to suspect that the most knowledgeable physicians may be sued the most. METHODS. We conducted a retrospective cohort study of family physicians who were included in the Florida section of the 1996 American Medical Association's Physician Masterfile and who practiced in Florida at any time between 1971 and 1994 (N = 3686). The main outcome was the number of malpractice claims per physician adjusted for time in practice. Using regression methods, we analyzed associations between malpractice claims and measures of physician knowledge. RESULTS. Risk factors for malpractice claims included graduation from a medical school in the United States or Canada (incidence rate ratio [IRR] 1,8; 95% confidence interval [CI], 1.6 - 2.1), specialty board certification (IRR 1.8; 95% CI, 1.6 - 2.1), holding the American Medical Association Physician's Recognition Award (IRR 1.4; 95% CI, 1.2 - 1.7), and Alpha Omega Alpha Honor Society membership (IRR 1.8; 95% CI, 1.1 - 3.0), Among board-certified family physicians, sued physicians who made no payments to a plaintiff had higher certification examination scores than nonsued physicians (53.48 vs 51.38, P < .01). The scores of sued physicians who made payments were similar to those of nonsued physicians (51.05 vs 51.38, P = .93). CONCLUSIONS. Among Florida family physicians, the frequency of malpractice claims increased with evidence of greater medical knowledge. [ABSTRACT FROM AUTHOR]