Dealing with troubling requests that can bedevil patient provider communications
Doctors are often confronted with patient requests for unnecessary or inappropriate procedures or medications. In a survey of over 2,000 physicians, they reported that a median of 20.6% of medical care was unnecessary, with the two most common cited reasons being fear of malpractice (84.7%) and patient pressure/request (59%). The report on the survey concludes that suggestions from physicians should be a part of the solution.
Though we naturally want to help people, learning how to say No to patients in a professional manner that preserves the doctor/patient relationship is a required skill, for which providers receive little or no training.
In my four decades of private urology practice, I’ve certainly had my share of requests that made me uncomfortable and put the relationship at risk. Let me share some situations that occurred in my practice and how I handled them.
How doing favors breaks the medical code of ethics
“Can you give me extra days off work after my procedure?”
A prostate surgery patient at the six-week follow-up asked me to prescribe in the paperwork two extra days off from work even though he was medically capable of returning. “I have some things to take care of around the house, and I haven’t been fishing for months,” he told me.
Ethically speaking, giving the man two extra days before returning to work was wrong as it was not necessary. He was essentially asking me to abuse my authority for his personal desires. Here’s what I told him:
“Mr. Patient, you are asking me to lie for you. I want to be consistent and honest with you at all times. I would never, ever lie to you nor will I ever lie for you. My professional and personal ethics require that I always tell the truth to anyone who has authorization to know about the particulars of your care, that being your employer and your insurer in this case. Now, Mr. Patient, will you agree to return to work tomorrow? Because I am not going to approve the extra days. You’ll have to make arrangements to go fishing on your own.”
Using this approach, I have not had one patient persist and ask me to lie or do something unethical. If needed, you can couch the honesty aspect in terms of what the patient might tell his child or grandchild about lying. But hold your ground. Giving in on this can only cause you more trouble with this patient down the road – and he will surely tell his fishing buddies that Dr. Baum lied to his employer so he could go fishing.
Doctors rarely escape the dreaded request for pain meds
“Will you prescribe me strong pain medications?”
Just about every doctor in any field gets this request. Beyond testing your medical code of ethics, it can involve serious drugs with abuse potential, like opioids. Assuming the request is not indicated for the patient’s condition, you can respond in the following manner.
“Mrs. Patient, I’m sorry but I can’t prescribe this pain medication for you. It is not indicated for your condition. I am happy to discuss non-prescriptive alternatives and ways you might reduce or manage your pain without the medication you are requesting. Would that help you?”
In denying the request, it’s important that you be firm, be kind and don’t argue. It is a good idea to have a policy in place about not prescribing unnecessary pain meds and to tell the patient about it. Also, make sure to alert other practice staff about this patient’s request in case he or she calls back. You can also offer to refer the patient to a pain management specialist.
Similarly, we often get requests for other kinds of inappropriate medications by patients, especially these days due to direct marketing to patients by drug companies.
Question: “Doctor, I saw an advertisement on TV about a new drug used to treat overactive bladder. Would you please write me a prescription for this new medication?”
A correct response might be: “That drug is called a third-tier medication and your insurance company will not pay for this medication unless you have tried one of the other, less expensive medications. Let’s see if that drug resolves the problem. If not, then perhaps I can prescribe the newer medication and then the likelihood is that the insurance company will consider approving the prescription.”
Although the majority of patients are appreciative and grateful for the care we provide, there are occasions where kid-glove management, tact and firmness must be used.
The unnecessary medical procedure tests the doctor code of ethics
“My relative had a brain tumor so I need a CT scan.”
Requests for specific procedures or tests are another example of a way patients seek – and often receive – inappropriate treatment. For instance, a patient tells you, “I’ve had a headache for two weeks. My father had a brain tumor, and I think I need a CT scan of my head to rule out a brain tumor.” Here’s how I would handle that:
“Your headache is intermittent and is relieved with Tylenol, which makes a brain tumor very unlikely. You also indicate that you were under a lot of stress providing care for your mother and that may be a contributor too. Let’s continue to use this mild analgesic/pain medication for your intermittent headaches and reassess the situation in two weeks. I hope that is an acceptable alternative, because I can’t order the CT scan at this time.”
It is important to be on the same page as the patient and to make the patient feel that he/she took a role in developing a solution. Asking the patient for buy-in makes turning down a request more palatable.
Asking for a relative’s medical records
“Can you send me my mother’s medical records?”
First, I would always ask the adult son or daughter the reason for the records request in case there was a problem with me or my office that needed to be addressed. I would then respond like this:
“I would be happy to provide you with a copy of her medical records. However, the law requires that I have permission from your parent before I can share his/her records. This requirement is for the protection of the patient. I can even accept telephone permission from your parent, then send you the records as soon as I have authorization.”
Accepting phone permission and then documenting the permission in the patient’s record is a reasonable solution and will avoid obtaining written permission which can take days or even weeks to accomplish.
Adjusting your medical practice to reasonable requests
“I know your office is closing soon, but can I wait here until my ride comes?”
Not all requests push the envelope of the doctor’s code of ethics. Some just require a little flexibility and minor adjustments. Many patients are dependent on family, friends or public transportation to get to and from appointments. Especially when friends and family are involved, these rides can run late. Here’s how you can honor this request in a reasonable manner:
“Of course, you are welcome to remain in the office until your ride arrives, if that’s in a reasonable time. I will see which employee we can have stay after hours for a while because we certainly don’t want you to wait out on the sidewalk. Do you have an idea of when your ride will arrive? If it is longer than 20 or 30 minutes, we can obtain an Uber, a Lyft or a taxi. I hope that will work for you. We could recommend a comfortable public place nearby we can take you to where you can safely wait for your ride.”
You may have to pay a little overtime for the staffer to stay on, or you could always stay yourself and do some work. The main thing is you do not want to turn this person’s request down out of hand. You want to be accommodating, but that has to be up to a point. That’s why establishing alternate solutions up front is wise.
Document the request that challenges the medical code of ethics
Let me emphasize the importance of documenting in the chart the patient’s request that would violate your medical code of ethics. It is imperative to document why the facts don’t support the patient’s request, and your reasoning for your decision.
You want to be absolutely certain that anyone who looks at the patient’s chart understands why the request was denied. Should the patient make a complaint to the local medical society or the insurance company or seek legal counsel, you will be relieved that you documented the encounter and the explanation behind your decision in the chart.
Every doctor encounters unreasonable or inappropriate patient requests that go against the medical code of ethics and sound practice management. Although the majority of patients are appreciative and grateful for the care we provide, there are occasions where kid-glove management, tact and firmness must be used. If we always advocate for what is in the best interest of the patient, then we will be able to say that “we practiced good medicine” – that we are able to defend our decisions and be able to sleep at night.