Saying or hearing “no” in any circumstances involves setting a limit with others or having them set a limit with you. It invariably involves some degree of confrontation. Although learning to say no can be liberating, most people would prefer not to be put in situations where setting limits is necessary.
One of my least favorite but necessary tasks as a physician is saying no to patients.
In the ideal world, doctors wouldn’t have to deny patient requests. Patients would read information only from reliable web sites. Direct-to-consumer marketing of pharmaceuticals would not exist. Patients with addiction histories wouldn’t ask for potentially habit-forming pain and anxiety medications. Doctors would always listen carefully to patients. Doctors would arrive at carefully thought-out formulations of their patients’ problems and then would explain all reasonable treatment options thoroughly. Ultimately patients would then make informed, logical decisions about their health care. Everyone would be happy!
But that’s not reality. All too often patients’ ideas become tainted by misinformation or aggressive marketing tactics. Doctors do not always listen carefully. Some patients see their doctor as a means to an end and believe that instead of the doctor playing the role of consultant to them, the doctor is there to provide them with the diagnostic and treatment interventions they desire. In fact, studies have shown that in 10% of outpatient visits, patients ask for specific medications. In correctional settings, based on my personal experience, I’m sure that number is much higher.
Physicians are therefore placed in the uncomfortable position of wanting to do the right thing. They want to avoid causing harm (medications, procedures, and diagnostic tests involve varying degrees of risk), avoid wasting health care dollars (any test or treatment costs money, but the newer medications advertised on TV tend to be quite expensive), and avoid any intervention that they believe is unnecessary or arbitrary.
But they also do not want to disappoint their patients or make them unhappy.
So, since conscientious doctors must say no at times, what is the best approach they can take to minimize the negative impact of saying no on the doctor-patient relationship?
The Archives of Internal Medicine recently published a study looking at this issue, “Getting to ‘No’: Strategies Primary Care Physicians Use to Deny Patient Requests.”
In this unique study, standardized patients presented to primary care doctors with symptoms consistent with major depression or adjustment disorder. Each also had an unrelated pain complaint. The patients specifically requested an antidepressant.
In 44% of the visits, the request was denied. Physicians were found to use 3 different strategies for saying no. Six percent used outright rejection (the request was denied without explanation), 31% used biomedically based rejection (a diagnostic workup was ordered or a sleep aid was prescribed), and 63% used a patient perspective based approach (the context of the complaints was explored, referral was made to a counselor, or an alternative diagnosis was considered).
Not surprisingly:
Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P=.001).
Therefore, although patients didn’t like being told no, it was a more positive experience if the doctors took them seriously, listened to and discussed their concerns with them, and in some cases referred them to mental health professionals.
Although the results of this study may not be shocking, this study matters because it draws attention to and opens the door for further research on this important topic. These results also are consistent with my experience with treating many inmates, a group who can be rather demanding at times.
In general, I believe the following approach works well when patients begin appointments not seeking professional input but asking for specific tests or treatments:
- First, listen. Try not to get upset. Do not get defensive. It’s so easy to become irritated and begin saying no before the patient has even had a chance to explain himself. Even if the request is not entirely appropriate, at least part of the request might be.
- If you agree that a request is appropriate, then grant it. There’s no reason for a power struggle.
- If you disagree, then clearly and honestly explain why. But, don’t focus on what you can’t do or are uncomfortable doing. Instead, focus on the patient’s concern and, if there is another approach that may help the patient, offer it.
Bottom line: Demonstrating an honest concern for the patient’s well-being and trying to find a mutually-agreeable solution, even if it’s not the one that the patient initially asked for, will go a long way toward both providing appropriate medical care and maintaining one’s working relationship with a patient.
Photo by oooh.oooh
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