Learning to parry patient requests

Today's assertive patient assumes numerous guises: the man with back pain insisting on an MRI; the worried mother who won't leave without an antibiotic; the recently diagnosed patient who carts along a stack of medical studies.

Jenni Levy, ACP Member, estimates that easily half of her patients arrive with a clear sense of what they desire from the visit. A far smaller number become pushy, even after encountering physician resistance, said Dr. Levy, medical director at St. Luke's Hospice in Bethlehem, Pa., and vice president of communications for the American Academy on Communication in Healthcare. “I think the way that we approach things [as physicians] can significantly reduce the amount of conflict,” she said.

Negotiating those doctor-patient dynamics, though, is easier said than accomplished, given the amalgam of personalities and other stresses that can thread through any given encounter. Time-pressed physicians must not only quickly sort through the patient's initial request, but also decipher the underlying medical issue.

“Often when patients ask for thing A, they really want thing B,” said Richard L. Kravitz, FACP, MSPH, a professor in the department of internal medicine at University of California, Davis and a long-time researcher on the doctor-patient relationship.

Add to that mix malpractice worries. Nearly all physicians believe that fears of a lawsuit result in unnecessary tests or procedures, research shows. Responses from 1,231 doctors, including internists, put the figure at 91%, according to a study published in the June 2010 Archives of Internal Medicine.

Are doctors possibly too accommodating? A 2007 Archives of Internal Medicine study found that patient expectations were met, albeit sometimes with an alternate recommendation, nearly 90% of the time. “What we found is that people get what they want, but that doesn't mean that it's all appropriate,” said James Tulsky, FACP, a senior author on the study and professor of medicine at Duke University in Durham, N.C.

The study didn't examine treatment appropriateness; an independent panel would have to assess that, Dr. Tulsky said. But the high rate of met expectations, among other study findings, makes him question whether doctors are sufficiently pushing back. “I don't have anything to substantiate it; it's just a suspicion,” he said.

With better communication techniques, doctors can chart a middle path, one that addresses patient needs and optimal medical practice, said Dr. Tulsky and other experts. Not every patient dispute can be avoided or fully defused, they stressed. But closer listening, along with a dose of empathy, can more frequently isolate the true concern and improve the doctor-patient relationship in the process.

Weighing rejection

Doctors, through years of practice, quickly become adept at various ways of saying “no.”

Rarely do they state so outright without elaborating or presenting an alternate path, according to another Archives of Internal Medicine study published in February 2010.

In that study, which involved patient actors and 199 primary care visits, physicians declined to prescribe a requested antidepressant 44% of the time. But of those rejections, just 6% were flat-out “no's,” according to the findings. The remainder of the time, the doctor explored the request in more detail or offered an alternate diagnosis or approach, such as a diagnostic workup or a referral to a mental health professional.

A blunt rejection, without elaboration, is frequently indicative of an outlier style of practice or a strained doctor-patient relationship, said Dr. Kravitz, an author on the February 2010 Archives study. “Those kinds of words tend to be destructive, even if they are true,” he said. “The patient experiences them as a rejection of themselves and not just of their request.”

Instead, Dr. Kravitz recommended teasing out what the patient really wants. One strategy is not to answer a direct patient request, but rather to respond with some related questions. If the patient asks for an antidepressant, the physician might say, according to Dr. Kravitz, “‘I'm just curious why you thought that might be a good therapy for you. Let's discuss this some more.’”

Another avenue could be to suggest a contingency plan. Rather than telling a patient with respiratory miseries to go home and cope with what is likely a cold, the doctor can instead write an antibiotic prescription with the proviso to only fill if the symptoms persist. “Time is one of our most important diagnostic tools,” Dr. Kravitz said. “Most of the time a waiting period will solve the problem.”

One challenge in these doctor-patient exchanges is that too many physicians are more comfortable talking in cognitive terms, reeling off facts related to treatments, tests and potential diagnoses, Dr. Tulsky said. “But if you stay only in the cognitive realm, then you are unlikely to find out why the patient is really making the request,” he said. “And you are unlikely to address what their concern really is.”

When a patient advocates for an MRI, they may actually be saying that they are very worried about their back, Dr. Tulsky said. A more emotionally sensitive response, he suggested, would be to say, “We could do an MRI. First, though, I'd like to hear what's on your mind. What concerns you most about your back?”

Too responsive?

In questioning whether physicians may be too acquiescent, Dr. Tulsky cited a couple of other findings from his Archives study. The doctors involved said they wouldn't have ordered 45% of the tests or medications requested if the patients hadn't directly asked. Plus, patient requests for medications and tests were fulfilled at a far higher rate, 75.6 % and 71.4%, respectively, than requests for a specialist referral, at 40.8%.

It's an easy default to scribble a prescription to satisfy a patient, Dr. Tulsky said. “It gets them out the door and it makes your day easier.” Referrals can be influenced by other factors, such as the patient's insurance coverage. But they also expose a doctor's practice style to a colleague, including the referral's appropriateness, he said. “I think doctors are very sensitive to how their colleagues perceive them.”

Another intangible that's difficult to quantify is the background influence of malpractice fears, said Tara Bishop, ACP Member, an assistant professor of public health in the division of outcomes and effectiveness research at Weill Cornell Medical College in New York. Dr. Bishop, lead author on the study involving defensive medicine findings, said that her data are consistent with other studies. “A large percentage of physicians feel like they have to practice defensively in order to prevent getting sued,” she said.

Still, it's difficult to sift out subtle influences, even for the individual physician involved. Dr. Bishop described one recent patient who arrived carrying a 10-page medical history, including a history of specialist referrals, and complaining of abdominal pain. Dr. Bishop ordered a CT scan. The image didn't reveal any problems.

Was she simply responding to a proactive and educated patient, or did malpractice fears play a role at all? She couldn't say for sure. “I think the hardest area is these gray-zone decisions where you could go either way,” she said.

Communication breakdowns

A few physicians reported that some patients appear to be responding to recent public discussions about excessive testing and treatment. “I think that the public is coming to understand that more is not necessarily better,” Dr. Bishop said, giving antibiotic overuse as one example.

Matt Hollon, FACP, MPH, who has previously written about direct-to-consumer drug advertising, has noticed at least some shift in patient attitudes toward drug advertisements in the last five years. “Oftentimes I see patients who have some skepticism about the advertisements, or have some skepticism about whether this drug is really the right drug for them, or whether there is a less expensive and easily effective alternative,” said Dr. Hollon, who is a faculty member at Internal Medicine Residency Spokane and clinical associate professor at University of Washington School of Medicine in Seattle.

If a patient remains insistent, their request is more likely to involve a lifestyle concern, such as hair-loss prevention medication, Dr. Hollon said. When teaching medical residents how to handle direct drug requests, he trains them not only to find out why patients want to take a particular drug, but also to educate patients about benefit to risk. Ideally the stated risk reduction should be presented in two different ways, the relative risk and the absolute risk, to help patients better understand how they might personally benefit.

Despite physicians' best efforts, communication can hit a logjam, Dr. Tulsky said. “Some people will remain quite unsatisfied if you don't do what they want.” And other issues can foster distrust, whether economic or racial differences, or simply that the patient is recovering from a bad experience with a prior doctor, he said.

Today's shift to a more proactive patient model can have ripple effects in the doctor's office, Dr. Kravitz said. “Consumer medicine has an upside,” he said. “But taken to an extreme, it is also a denial of a physician's professionalism. So there is an emotional component to this.” In some instances, he said, the doctor is “reacting not just to the request itself, but what it means in terms of the patient's trust and acceptance and value in the physician's training and knowledge.”

Also, doctors can dig in their heels for no good reason, Dr. Levy said. “Because they feel attacked, because they feel demeaned, because they are tired and frustrated and hungry and didn't get lunch,” she said.

In that scenario, the best strategy is for a doctor to provide himself a time out, Dr. Levy said. Make your pager go off, she suggested. Step out for a drink of water. “Get yourself out of the situation.”

Once on the other side of the door from the patient, formulate what you want to do and develop an empathetic statement. “Such as, ‘I understand how difficult this is.’ Or, ‘You must be really concerned about this,’” Dr. Levy suggested. Then try to find some middle ground together, she said.

“You can say, ‘It seems like we are really in different places about this.’ Because it's obvious—why not say it?”

Practicing style

Still, two doctors who strive to identify and address patient needs may not necessarily reach the same conclusion. Drs. Levy and Tulsky talked about a common scenario, in which a patient advocates for a particular antibiotic. “In most cases, for respiratory infections, it doesn't matter that much,” Dr. Levy said. “In that case, I will do it for the sake of the relationship. I won't do something that I think is frankly harmful.”

Dr. Tulsky agreed with the antibiotic interchange, saying “although one antibiotic may be preferred, an alternative is pretty reasonable.” He added, “There is a huge placebo effect in everything we do.”

But they differed on how to handle another scenario, a 70-something woman complaining of a few days of cough who wants a chest X-ray to rule out pneumonia. Typically, Dr. Levy will conduct a physical exam and provide an explanation of why pneumonia doesn't appear likely, as well as offering a backup plan: ordering the X-ray if the cough continues. Nearly always those steps are sufficient, she said. If not, she might order the chest X-ray to ease the woman's excessive anxiety.

Dr. Tulsky, when asked, seemed less prone to ordering the test. “I don't think that treating something is the appropriate avenue to reduce anxiety,” he said. “Addressing anxiety is the way to reduce anxiety. I just feel like you don't have to do it. It's radiation to the individual and cost to the [health] system.”