Health & Medicine - Posted by Charles Casey-UC Davis on Tuesday, March 2, 2010 21:33 - 4 Comments 
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(2 votes, average: 4.50 out of 5) Loading ...When doctors just say ‘no’
When denying requests for inappropriate treatments, physicians can preserve their relationships with patients by doing so in a way that addresses the patients’ concerns. “Our study found that physicians rely on three types of strategies to deny patient requests, and that the strategy that seems to suit patients best is one that includes and specifically addresses patients’ viewpoints and motivations,” says Debora Paterniti. (Courtesy: iStockphoto)
UC DAVIS (US)—It’s possible for clinicians to turn down requests for inappropriate treatment and still address the patient’s concerns and preserve the physician-patient relationship.
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“Physicians face a dilemma when their patients request an inappropriate treatment,” says Debora Paterniti, associate professor of internal medicine and sociology at the the University of California, Davis. She is lead author of the study published in the Archives of Internal Medicine.
“On one hand, physicians want to avoid a course of action they believe is unwarranted. On the other, they want to maintain the trusting relationship they have with their patient.
“Our study found that physicians rely on three types of strategies to deny patient requests, and that the strategy that seems to suit patients best is one that includes and specifically addresses patients’ viewpoints and motivations.
“We believe that physicians, equipped with a more nuanced understanding of physician-patient communication about how to say ‘no,’ may consider these strategies for denying requests from different types of patients.”
For example, patients request medication during approximately one in 10 office visits. While most requests are granted, medications prescribed at the behest of patients may not always represent physicians’ first choice of treatment, particularly if the requests are commercially motivated, as for example, by direct-to-consumer advertising.
Nevertheless, physicians are cautious when rejecting patient requests for services because, as some studies have indicated, unfulfilled patient requests are associated with reduced patient satisfaction. Previous research also has shown that physicians may choose to fulfill inappropriate requests when they believe their patients expect the request to be granted.
Paterniti and her colleagues analyzed data from a randomized trial on the behavior of primary care clinicians in response to requests for antidepressant medication. Standardized patients who were trained to request antidepressants made 199 initial visits to primary care offices in Sacramento, San Francisco, and Rochester, N.Y., in 2003 and 2004, complaining of “feeling tired” and also of either wrist or low back pain.
Transcripts of audio-recorded visits in which requests were denied were analyzed and assessed for strategies used to communicate denial.
Of the 199 visits in which antidepressants were requested, clinicians did not prescribe them in 88 (44 percent), and 84 of those were included in the analysis. Clinicians used six primary approaches to deny the requests.
In 53 of 84 visits (63 percent), physicians used one of three strategies that emphasized the patient’s perspective.
These approaches included exploring the context of the request by asking questions about where the patient heard about the drug and why they thought it would be helpful; recommending that the patient seek the advice of a counselor or mental health specialist; or offering an alternative diagnosis to major depression.
In 26 visits (31 percent), clinicians took biomedical approaches, either prescribing sleep aids instead of antidepressants or ordering a diagnostic workup to rule out conditions such as thyroid disease and anemia. In five visits (6 percent), clinicians simply denied the request outright.
The standardized patients reported significantly higher visit satisfaction when the physician explored their reasons for a request, and acknowledged the patients’ interpretations and perspectives when denying their request for antidepressants.
“These strategies provide physicians with alternatives for saying no to patient requests for care that is perceived to be inappropriate, offering physicians an opportunity to select approaches that fit their own style of communication, the preferences of particular patients or changing organizational climates,” the authors conclude.
The study was supported by a grant from the National Institute of Mental Health.
UC Davis news: www.news.ucdavis.edu/
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4 Comments
Paul
The problem I have had is in the doctors denying what I know was the cause of the condition. It is mind boggling to go to a Dr for assistance and being told , what is in effect, that you are to ignorant to know what caused the medical problem that you are afflicted with. I realize that our medical system isn’t geared toward finding out what caused the condition, only what medicine the Dr should prescribe to treat the symptoms of the condition. However when treating the symptomds you do not want to make the problem worse which is what happened top me back when I would defer to the “wisdom” of the attending physician. *In my case I was overdosed with fluoride by an improperly applied fluoride treatment. I was also nutritionally deficient in the nutrients that would have helped to weather the overdose, When I told the first physician what had happened at the oputset of my physical and nuerological breakdown, she denied that fluoride could possibly be a cuase. In my naivete I took that as a well thought out diagnosis and moved onto to other possible causes. As it turns pout I spent a year and a half in pure physical and mental hell till I realized that I should have listened to my gut instinct and pursued the connection between the dental appointment and the dibilitating condition that followed. After going top three Drs who all denied the possiblity that the nuerotoxin fluoride could have caused my nuerological problems I took steps to eliminate my unkowningly continued exposure to fluoride in my water, diet, medicines, etc.. For the past six months I have been making a slow recovery but now have a Dr who still denies that fluoride could be the poison that took me down. I don’t know if they are doing this oput of comraderie with the dental profession, out of ignorance because it wasn’t mentioned in Medical school or in the latest medical journal or what. My Dr even said {” In ten yers of practice I’ve never heard of such a thing” So then I guess it doesn’t exist then if a Dr hasn’t heard of it yet. Yes fluoride is a poison that the human animal has no need of, it is a substance that the human body has to deal with in nature but has no nutritional need of let alone be supplemented with.
Paul
No I’m not illiterate, I just can’t type well and I didn’t spell check before I sent it off. :-)
Paul,
I always listened to my patients. Believe me, mother does know best. Sometimes grandmother has some good ideas too. Men have a tendency to say there is nothing really wrong. The problem is often that a patient has difficulty describing what is wrong and the doctor jumps to the wrong conclusions. In your case the amount of flouride must have been a hundred times the amount normally used. It sounds like a “dismal point” error. (That is what we call it in private.) Good luck with your recovery.
In 40 years in the medical field I have seen multiple variations on how to treat a patient, particularly patients who have their own ideas as to their problem. This has ranged from doctors who give the patient what they want to ones who always argue with their patients. The biggest problem has always been time. On the average a medical doctor has about 10 minutes with each patient. In that time he has to evaluate the patient, consider their complaints, (which are often vague and/or non specific), formulate a plan of treatment, and explain the plan to the patient. It is easier to deal with the patient who is honestly seeking help as opposed to the patient who already knows he or she has the same thing Aunt Edith had last year. Each type of patient requires a different approach. After a session with the “Aunt Edith’s it is often the doctor who needs the antidepressants. Then you have to deal with the insurance company, who see no need for the doctor to do more than give out pills.