Couch a No in an Explanation
Straightforwardly telling a patient, "No, you can't have that drug, test, study, or appointment," maximizes the odds that the news will not go over well. There's a more diplomatic, less confrontational way to achieve the same result.
"A patient might say, 'I need an MRI for a brain tumor,'" says internist Matthew Mintz, MD, associate professor of medicine at George Washington University School of Medicine, who has a private practice. "I don't reply, 'No, we're not going to get the MRI.' That's not my initial response. I might say, 'Well, an MRI is an option, but let me tell you what I think we should do or what the best option for you is.'"
"When time is an issue, patients know that they have only a few minutes for a visit, so if they want action, they're going to ask for it," Dr Mintz reflects. "My initial reaction might be to say no, but that can set up a conflict. Instead, I try to say no by not saying no—by saying, 'Okay, we can consider your request, but let me tell you what I think.' I find that works 99% of the time."
"At the end of the day, you have to go to sleep and know that you did good medicine," agrees Bradley P. Fox, MD, a family physician in private practice who is on the clinical faculty at Gannon University in Erie, Pennsylvania. "How do I approach it? I make sure that any time I say no, it's not just no; it's "No, because ...," or "Not exactly."
"Do I cut patients off? Sometimes," Dr Fox admits. "'You do not need an antibiotic because this is viral. Viral illnesses do not get better with antibiotics.' But most of the time I couch it in: 'Here's what we're going to do.' No is not no so much as it is, 'Not now,' or 'No, because ...' It wasn't a no, but it was no."
Open a Discussion
When a patient makes a specific request that you're not willing to accede to, you can diffuse potential conflict by taking a moment to understand the "why" behind the patient's request.
"First, head for the real issue: What are they afraid of?" says William Sonneberg, MD, a family physician in Titusville, Pennsylvania. "It's not that they want that product. Probably they don't want that product. But they have something they're worried about. You have to peel that back—peel away the advertising, if that's where they got the idea—and head toward the main issue."
"It requires persuasion," Dr Sonneberg adds. "If they want an antibiotic, you have to wonder why and seek to understand it. A lot of times patients will say, 'My husband had bronchitis. I have it too.' And you have to say, 'Yes, an antibiotic is commonly prescribed for that, but it's a mistake.' You have to tell patients that if it's that contagious, it probably is viral—that 95% of bronchitis is viral and really should not be treated with an antibiotic."
Dr Mintz occasionally gets a request for vitamin B12 for obesity management. "I do believe in the use of pharmaceuticals for obesity management," he says. "But there are both prescription and nonprescription drugs that patients use or ask for that are not effective. B12 is the best example. B12 is the most abused prescription substance in the medical community. It does absolutely nothing, but a lot of medical obesity clinics offer B12 shots at steep markup."
When Dr Mintz explores why a patient wants B12, he often hears, "'I'm taking this supplement that I saw on TV that says it'll burn my fat, and I don't have to do anything,'" he says. "I tell the patient, 'There's nothing that will burn your fat and you don't have to do anything else. If there were a miracle cure out there, don't you think I would give it to you?' It's debunking some of the stuff that they've heard or seen on TV."
"A lot of times, people come in and ask about the new anticoagulants, which are always advertised on TV," says John Mandrola, MD, a cardiac electrophysiologist at Baptist Medical Associates in Louisville, Kentucky. "I think there is a balance between warfarin and those drugs; we have a conversation about that, and usually it works out just fine."
"Giving an explanation opens a discussion," Dr Fox says. "The biggest problem with a yes/no answer is that it closes the door. By closing the door to a discussion, it opens the door for patients to walk into an emergency room, call the insurance company, or call the hospital because they weren't happy."
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Neil Chesanow. 10 Ways to Say No to Patients -- and Still Keep Them Smiling - Medscape - Feb 17, 2016.