10 Ways to Say No to Patients -- and Still Keep Them Smiling

Neil Chesanow


February 17, 2016

In This Article

Match Your Response to the Patient

When Charles Davant, III, MD, a family physician in Blowing Rock, North Carolina, has to tell a patient no—for example, when a patient requests an antibiotic for a viral infection—he considers a number of factors about the patient as a unique individual in his practice.

"First, it depends on how well I know the patient," he says. "And it depends on the patient's level of education. There are a few people we see where we know they'll be in the office three times if they don't get an antibiotic. And there are other patients who are here and are pretty sure they don't need an antibiotic, but they just want to make sure. So educational level plays a role."

Framing a response to the patient with a view to who the patient is as an individual isn't just important for PCPs. Take cardiac electrophysiology (EP).

"Atrial fibrillation (Afib) gets put into a silo of a disease, like a gall bladder problem or appendicitis," Dr Mandrola says. "Patients have this view that I've got a problem, and I want a fix. A lot of times, though, taking care of Afib is more about managing the problem and aligning whatever treatment is best for that patient with what their goals are. With Afib, it has to be personalized, and what's right for you might not be right for me. My job is balancing that. Many patients want the doctor to decide, but in EP many treatments are preference-sensitive."

Deflect the Blame

There are times when you need to say "no" to a patient that are not solely your decision. But because you're the only one in the room with the patient, it's okay to deflect the blame to the absent party to make life easier on yourself.

Take the patient who feels a twinge of pain in his back and whose friends tell him, "You tell your doctor you need an MRI."

"That's actually gotten easier lately as insurance companies have gotten tougher," Dr Davant observes. "When a patient comes in, and they've only had back pain for a week or 10 days, I tell them, 'We can try to get it precertified, but then the insurance company will say, 'You've only had pain for 10 days and it's not radicular. We're not going to cover the MRI until you've had physical therapy and this has been going on longer.' That way, I can tell the patient, 'It's your insurance company. You'll have to do this, this, and this first. Otherwise, you'll have to pay out of pocket.' That way the insurance company is the bad guy, not me."

Sometimes clinical guidelines can play the role of bad guy—as, for instance, when a patient who isn't obese requests diet pills.

"Diet pills are fairly easy," Dr Davant says. "Some guidelines have a cutoff of a BMI of 30 or 35, depending on whether you have comorbidities. I can tell patients, 'You're not fat enough. Go out and gain another 15 pounds.' Specific guidelines are useful, particularly things that you can show people and say, 'That's why your insurance won't pay for it.'"


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