The Art of Saying No to Patients

Saying No is an art of its own

Despite the fact that we all want to be accommodating to our patients most of the time, not all patient requests should be fulfilled. The art of saying no in patient care sometimes depends on how well the health care provider can explain to patients why some medications or treatments may be ineffective or even harmful.

There are many situations in which a patient may request a particular medication or procedure that is not really in their best interests. This is especially true these days since there is so much medical information being dispensed over the Internet and in television advertisements. Patients frequently identify with symptomatic patients in advertisements and think the promoted medication should be good for them as well. In addition, circles of well-meaning friends will often suggest treatments for various ailments to each other.

As a result, patients will often come into the office requesting a trial of diet pills, sleep aids, analgesics, steroid injections, hormone therapy, B12 injections, thyroid medication, etc. Many of these items that patients request may be helpful to them, but many may be harmful. As the patient’s primary health care provider, you need to be able to say no sometimes to those things that you think would not be desirable for their health – either short term or long term. The patient may have already made up his/her mind about the necessity of what they are requesting; and depending on how strongly they feel about it and how adamant you are against it, the conversation may turn confrontational.

What is the best way to handle these situations before they damage the doctor-patient relationship?

There are several different ways to say “No”. The following methods are often used in one form or another, and they can result in greater or lesser degrees of effectiveness and satisfaction:

Saying No with Authority

Perhaps the simplest and the oldest method, but the least effective and most unsatisfying to the patient is to “Just say no” with no explanation or a cursory one at best. In the old days when patients regarded their physicians as symbols of authority whom they did not question, this might have worked. In the new millennium however, this is not effective, is often considered condescending or demeaning, and is very unsatisfying to patients who rightly want to understand and want to be involved in their care.

Saying No with Information

The second approach would be to not deny the request right away, but try to gather more information, which could be obtained from careful history and examination and/or by ordering appropriate tests to verify the need for whatever the patient is requesting. This may take the onus off the physician and place the decision on the results of a lab test. For example, in the case of a request for a B12 shot, you might say, “If the B12 blood test is too low, then yes, of course, we will give a B12 injection. If the test is normal, however, then you really won’t need it. This is more effective than the first method, but still may not be well accepted.

Saying No with Understanding

The third method is to provide a careful explanation as to why the requested procedure or treatment would not be helpful to the patient and may even be harmful. In this case, you are placing the decision where it belongs – completely based on the welfare of the patient. This is much more likely to be accepted and to lead to the patient’s satisfaction that the concern has been properly addressed. The patient then comes away from the discussion understanding why his request for the antibiotic or the B12 shot or whatever was not in his/her best interest. The patient has been a participant in the discussion, has asked the right questions and has received a satisfactory answer, even though it may not be the one that he or she was hoping for. But the answer is understandable and therefore acceptable.

Saying No for Society’s Benefit

The fourth approach and the worst in my opinion is to blame your decision on your responsibility to society and the need to cut health care costs. This discussion has no place or credence in a situation where the doctor is trying to be the patient’s advocate and trying to keep the patient’s best interests at heart. This is a clear conflict of interest and significantly downgrades the doctor-patient relationship. Whatever feeling the physician or other provider may have about the need to protect society and protect the children of the future should not be verbalized to a patient who is depending on the doctor to act in his or her behalf.

I don’t deny that there is a need to pay attention to the broader issues of health care delivery and health care costs, but that cannot be part of the discussion about what is right for a particular patient. My contention is that if you follow appropriate medical guidelines for each patient, you won’t be over-ordering or under-ordering tests or treatments and you will be doing the right thing for the patient AND society at the same time.

Reference: Paterniti, et al, "Getting to 'No': Strategies Primary Care Physicians Use to Deny Patient Requests" Archives of Internal Medicine,Feb. 22, 2010, 170:4,pp381-388.

This page was last updated on February 24, 2010.

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