Saying No Without Being Negative
Patients often request tests or drugs that physicians believe aren't indicated. Saying "no" can prompt a conflict if not managed appropriately.
"Is the request for a specific drug based on something the patient saw advertised on television? They may not actually want the drug, but are really asking whether they have the problem the drug treats," says Roy. "They use the drug as a way to bring up the topic of depression or erectile dysfunction, or whatever. If they have the problem the drug addresses, are they dissatisfied with their current regimen?
"Does their insurance even cover it? We've been frustrated trying to get authorization for a drug, only to tell the patient that their portion of the cost may still be too high for them. We encourage them to find out what their expense will be before we seek authorization," she said. "The same applies to tests. The real questions a doctor must focus on are: What are we looking for? What will it change from what we're currently doing? What are the risks associated with the test?"
Joseph E. Scherger, MD, MPH, vice president at Eisenhower Medical Center, Rancho Mirage, California, will explain why a test isn't needed. But if the patient insists, he'll often agree to it as long as it isn't harmful. "The patient may have back pain and wants an X-ray I don't think is needed. But it won't hurt him, and it's not unreasonable to order it. It depends on the patient's insurance. The doctor doesn't have to be so hard-nosed. With rules for prior authorization, you can let the insurer be the bad guy and say 'no' to MRIs, etc.
"Tests are often a financial issue," he said. "Drugs are different. They can harm people. I won't prescribe drugs that aren't indicated, but you need to take the time to explain why. Give the patient your honest opinion."
Gerald B. Hickson, MD, senior vice president for quality, patient safety, and risk prevention at Vanderbilt University School of Medicine in Nashville, agrees.
"Patients come to the office in anticipation of getting a test or treatment. The doctor has to set the stage and make clear that it's our professional duty to evaluate the patient and make recommendations based on the exam and history and best practices. When parents ask for antibiotics for otitis media, I need to be willing to take the time to explain why it's not a good idea. I also say that I could be wrong and will see the child again and reevaluate if needed. That does a lot to diffuse tension and disagreement. Be respectful and not dismissive."
When saying "no" about tests, anticipate the anger. "Joe, I hear your request. I know you've been bothered by these headaches. It can be from tension, or from a more serious problem. My findings show that the headaches are inconsistent with the need for an MRI at this time," said Hickson. "Physicians need to let the patient know that you're thinking of the whole gamut of possibilities. They need to understand our thought processes or they'll be less likely to cooperate."
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Cite this: Those 'Difficult' Patients Whom You and Your Staff Dread - Medscape - Dec 04, 2014.