“Physicians face a dilemma when their patients request an inappropriate treatment,” said Debora Paterniti, associate professor of internal medicine and sociology at the UC Davis Center for Healthcare Policy and Research, and lead author of the study. “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 state.
Co-authors Paterniti, Tonya Fancher and Richard Kravitz were supported by National Institute of Mental Health grants.
The Center for Healthcare Policy and Research facilitates policy-relevant research in the areas of health-care access, delivery, costs and outcomes. The goal of its research is to improve the organization, quality and effectiveness of medical care, with a particular emphasis on comparative effectiveness and healthcare policy. The center provides research and consulting services to agencies in both public and private sectors. As an interdisciplinary unit comprised of over 60 health-care researchers, the center’s faculty represent disciplines ranging from business management, economics, and psychiatry to preventative medicine, epidemiology and statistics. For more information, visit www.ucdmc.ucdavis.edu/chpr