Saying "No" to Your Patient

In the current world where patients can get more information than ever about being sick and potential treatments, physicians might find themselves in the difficult situation of telling a patient “no” when he or she requests something unnecessary.

JAMA

In a recent column published in , authors Allan S. Brett, MD, and Laurence B. McCullough, Ph.D., express how physicians can address requests by patients for nonbeneficial interventions.

“Direct-to-consumer advertising prompts patients to diagnose themselves with conditions tied to advertised drugs,” explain the authors. They then go on to write that, “patients who misinterpret self-acquired medical information may request unnecessary or even harmful interventions.”

Disagreeing with a patient might be difficult for some physicians, who find themselves granting these requests. Many physicians don’t want to damage the patient-physician relationship, which relies on trust and goodwill. Others might just not want to take the time to explain why the treatment isn’t beneficial.

While patient autonomy is used to support a request, the authors don’t agree that a request should necessarily be granted.

“Using patient autonomy to justify acquiescence to patients' requests for nonbeneficial services violates professional integrity,” Brett and McCullough write, defining professional integrity as standards of intellectual and moral excellence. “Commitment to professional integrity requires that physicians challenge requests for nonbeneficial interventions.”

Another good reason for denying these sorts of requests is that ineffective interventions “account for a nontrivial proportion of health care costs.” Physicians might find themselves torn when it comes to using this line of reasoning. On the one hand, they should believe that costs shouldn’t influence clinical judgment. However, on the other hand, the U.S. is more aware than ever about health care spending and costs.

In managing requests for nonbeneficial services, physicians should justify their positions, invoke practice guidelines when appropriate, and offer suitable alternatives,” the authors conclude. “The resulting clinical encounter reflects the physician's role as educator and enhances deliberative decision-making in partnership with patients.”

How do you deal with patients who are asking for nonbeneficial interventions?