Saying no to a patient request can be a challenge. Physicians strive to maintain good relationships with patients, while not wanting to agree to anything not medically indicated. While this is certainly not a new problem, it is likely expanding due to inaccurate information on the Internet and direct-to-consumer advertising can increase patient requests for specific things.
Patient encounters that often lead to hard feelings can include denying a request for narcotics or antibiotics that are not warranted, refusing a request for a prolonged excuse from work, or declining to order costly tests that are not needed.
Many experts say that good communication is the key to managing these encounters in a way that does not escalate into bad feelings, anger, and poor patient outcomes.
David A. Fleming, MD, president of the American College of Physicians, says he believes conflict occurs because when the patient and physician disagree, the patient feels vulnerable and distressed.
“We need to recognize the power differential that is present,” Fleming says. “Patients are often fearful and uncomfortable and we need to help them work through that.”
Fleming says he often knows when an encounter is going to lead to conflict, and he follows a few guidelines to diffuse it.
First, always remain professional. “Address the patient respectfully. Don’t get reactive or respond in an emotional way,” he says.
Next, be empathetic and compassionate but do not be swayed from solid decision-making, Fleming advises. Explain clearly the evidence-based practice guidelines you are following.
Third, support and inform the patient. “Information can be powerful. Often conflict arises because there is lack of communication about the information that has been provided, either from the patient giving information to the physician or the physician convening information back to the patient,” says Fleming, who is also professor of medicine at the University of Missouri School of Medicine and chairs the Department of Medicine and is director of the MU Center for Health Ethics.
Always maintain a steady voice, use terminology patients can understand, and ensure they understand what you have told them before they leave, Fleming adds.
Catherine Hambley, PhD, an organizational psychologist with LeapFrog Consulting, recommends evoking the teamwork nature of the relationship at times like these.
“Say, ‘I am your partner in your healthcare,’” she advises. “Do not say ‘I am the doctor’ because ultimately it is the patient who decides what they are going to do about their health, not you.”
Robert A. Lee, MD, a family physician in Johnston, Iowa, and a member of the board of directors of the American Academy of Family Physicians, says that sometimes a physician needs to call out a patient who is getting angry.
“Some people are just nasty and they don’t get along with anyone, and you may just need to call a spade a spade,” he says. “I may tell them I know they have difficulties with relationships and if they want this relationship to work, here’s what I need from them and here’s what they can expect out of me. Open it up and have that frank discussion.”
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He uses pointed questions, such as asking about their relationships with their co-workers and their family. Do they have friends? Their answers can be very revealing, to him as well as to the patient. “When they start running through this, they make the connection,” he says.
Lee will sometimes say “you seem angry with me today.” This puts the focus on him, not them, which can lower their levels of offensiveness. “They may agree that they are being demanding,” he says.
Diffusing the situation at the time helps avoid patients developing the expectation that they can demand whatever they want from him in the future.
“Some of my most rewarding patient relationships started with us being at loggerheads, but once we worked through it, they are very loyal patients,” Lee says. “It feels great for me to earn their trust and for them to know I have their back.”
Arvind R. Cavale, MD, a specialist in diabetes and endocrinology in Feasterville, Pennsylvania, believes that patients who express anger or frustration at a denied request usually just want a thorough explanation.
Patients often ask him for a medication they saw advertised, such as testosterone. They complain that they are tired and the drug seems like a solution. Sometimes their primary care physician has even suggested testosterone and referred the patient to him. He tests them for low testosterone levels but often finds no justification for the medication. When this happens, he often has to “go back to the basics.”
“I tell them everyone is tired. No one sleeps well,” he says. “I ask them when was the last time they felt well. It is important that I understand their issues because what they really want is to feel better, not necessarily use a certain medication.”
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This can be time-consuming, but asking open-ended questions is the only way to get to the heart of their actual problems. “Once we do that, we can provide alternative options, in most cases,” he says. “We need to give them a reason to be optimistic when they leave.”
Jonathan Weiss, MD, an internist and pulmonary medicine specialist in Monticello, New York, doesn’t see a great deal of conflict in his office. He attributes at least part of that to his policy of not prescribing narcotics for new patients unless they have cancer.
“My office staff tells them this when they call, so we set the expectations upfront that narcotics are not on the agenda,” he says. “I used to engage in debates and negotiations about this with patients, but having a general rule short-circuits the whole conversation.”
Patients are told that Weiss is happy to work with them to manage pain, of course, but that he utilizes other approaches, such as physical therapy or referrals to an appropriate specialist, such as pain management, orthopedics, or psychiatry.
“I would employ this policy in other areas of my practice if I felt it was needed, but narcotics is the area in which it most frequently arises,” he says.
Several physicians noted that insurance can also be a factor when facing inappropriate patient requests. While they are willing to fight to get an approval for a legitimate patient need, they do not want to expend the time and energy for ones they do not think are necessary. They let an insurance rejection speak for itself.
Matthew P. Finneran, MD, a family physician in Wadsworth, Ohio, finds that changes in insurance can actually be helpful when denying a request for tests that he feels are excessive.
“The economies of healthcare today make it easier to insist on following evidence-based guidelines,” he says. “Plus, with many patients facing high deductibles, they are less adamant about doing something they will have to pay for.”
In fact, he sometimes finds this dynamic can make conflict run in the opposite direction, as some patients have to be convinced that a test is worth the out-of-pocket expense they will face. “This is always easier with a long-time patient who knows and trusts me already,” he says.
Some unhappy patients will attempt to talk a staff member into giving them what they want.
Weiss says he tries to counsel his staff to be as patient as possible when dealing with such requests. He offers occasional pep talks when staff morale seems to be flagging under the pressure. He also offers to take a call off the staff member’s hands if he is nearby and feels the staff member is being particularly challenged. “Sometimes, if I offer to talk, it helps deflate the situation,” he says.
He understands that staff members need to vent to each other sometimes, but encourages them to do it in private so they can maintain a happier face to the public. “We are not always successful but we do our best,” Weiss says.
Cavale says he works to instill his practice principles into his staff, and tries to empower them to interact with patients to the best of their abilities.
“They can’t make everyone happy but we should try to help them as best we can,” he says. “I remind the staff that the patient may have other issues going on at home or work and we should try to give them as much leeway as we can.”
Some patients will choose to leave a practice if their requests are not granted. Most of the physicians interviewed said they will help them make arrangements to do so, if they want.
“Maybe they will find that someone with a fresh eye will give them a different message, but often they still will have the same issues,” Lee says.
On occasion Weiss has told patients that they are welcome to find another physician if they did not feel he was meeting their needs. “This is usually a final play. Most do not take me up on it,” he says.
Hambley says that, rarely, some patients can get so upset with the physician that they may be unable to continue the conversation in a civil manner.
In those instances, she suggests the physician offer to go to see the next patient, giving the distraught patient a few moments to gather his or her thoughts before resuming the visit.
“Acknowledge their anger and stress that you want to get on the same page,” she says. “If you can really convey that message, it is much more likely that you will develop a trusting relationship in the future.”
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Provide written notice
The physician should issue a written termination letter to the patient prior to the effective date of termination. The letter should clearly state a termination date (we suggest 30 days in advance) and the reason for termination.
Include a list of suitable alternative providers
The letter also should include a list of alternative healthcare providers in the area, and if appropriate, referral to the patient’s insurance network.
Time the termination properly
Avoid withdrawing from treating the patient when the patient is in medical crisis, unless the patient requires the services of a different specialist and arrangements are made for transferring the patient’s care to such specialist.
Examine managed care contracts and communicate with health plans
If you are a participating provider in a managed care network in which the patient is covered, contact the payer, explain the situation, and ensure everything is done properly per the contract to prevent problems later.
Provide record access
Offer to send a copy of the discharged patient’s medical records to the patient’s new doctor. Numerous states have laws which require that records not be withheld solely because of a patient’s inability or refusal to pay.
Be sure to apprise all physicians and office staff members of the termination to avoid inadvertent reestablishment of the physician-patient relationship.
Source: Eve Green Koopersmith, JD