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

Neil Chesanow


February 17, 2016

In This Article

When Necessary, Be Firm

Most of the time, if you do it diplomatically, patients will take no for an answer. But sometimes they won't. In those instances, put your foot down—but gently.

"You have to really be firm with certain people," Dr Sonneberg admits, thinking of patients who insist on an antibiotic for bronchitis. "You have to take the professorial view. With some patients, you have to act like you're delivering the Sermon on the Mount and do it with authority and conviction. You can't waffle and say, 'Maybe there's a small chance I should do it to protect the patient.' You have to say, 'No, this is a virus.'"

"The analogy I always like to use is, 'If you use an antibiotic for virus, it's much like offering a fire extinguisher to someone who's drowning.' Your heart's in the right place. You try to do good. You're trying to treat something that's bad. But you're treating the wrong thing. A life preserver will not help you in a fire. I tell the patient, 'You need and deserve the right treatment. If I give you an antibiotic, the chances I'll hurt you are very strong.'"

"At that point, I sometimes go through a scare technique. I say, 'The chance that you'll be hurt by that antibiotic is far worse than the virus that we're trying to treat with it. For example, it increases your risk of dying of cardiac arrhythmia threefold. Frankly, I fear that more than I do bronchitis.'"

Patients seeking narcotics for pain under suspicious circumstances may also require a firm denial. "Most of our chronic pain patients have signed pain contracts and know that they're not going to get any early refills," Dr Davant says. "And they've learned that if they come in having 'lost' their medicine, they will be drug-tested right on the spot to see what else is on board."

If a patient is seeking amphetamines, Dr Davant has a policy for that as well. "If people who come in and want amphetamines and things like that—if they make a good case, I would probably give it to them, but only for a couple of weeks; I'm certainly not going to give a month's worth," he says. "But I'll send for their medical records. And I have a very good clinical psychologist whom I send college students to if they think they have attention-deficit disorder, and she puts them through a very nice evaluation, so I've got documentation. If someone comes in, and they've just moved to the area, I can probably get records from their previous doctor in a few days."

Sometimes Dr Davant gives patients a written rather than an electronic script, "because the latter goes straight to the pharmacy. I say, 'The weekend's coming up, and I think you'll be better in a couple of days. If you're not better in 3 or 4 days, go ahead and fill this and try it then.'"

Dr Sonneberg hopes that his expert opinion will be return on investment enough to keep patients content. "Oh, you mean I took all that time off from work, and you're not going to do anything?" he sometimes hears. To which he replies: "You took all this time off from work. You deserve the best treatment—the right treatment. You don't deserve something that's going to hurt you. In your case, with a viral infection, that's what an antibiotic will do. All medicines have side effects. You just have to make sure there's a chance of a benefit."


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