“Hey, doc, can you do me a favor?” This common question can quickly become one of the most challenging parts of your workday. Patients routinely ask for things that physicians feel are inappropriate.¹ Requests for opioids or benzodiazepines, work or school excuses, expensive tests or procedures, family and medical leave certification, and durable medical equipment are each wholly appropriate under the right conditions. But what do you do when the conditions don't support the request? Uncomfortable feelings and avoidance are common responses. Physicians may even find themselves saying yes and later regretting it. Others may say no but do so in a tentative or equivocal manner that undermines the patient's confidence in the physician, prolongs the visit, and leaves both parties feeling dissatisfied.²

Learning how to say no to patients in an effective, professional manner that promotes good patient care and preserves the relationship, while supporting physician well-being, is a required skill. In our experience, few physicians have this skill naturally. Without a framework for responding to inappropriate patient requests, they may have a tough time getting to no.

We have developed an approach for handling inappropriate patient requests that is simple, standardized, and easy to adopt. The FAVER approach, spelled incorrectly for our purposes, includes five steps to minimizing patient and physician conflict and maximizing quality and rapport. (For a one-page summary of the model, see “The FAVER approach: responding to inappropriate patient requests.”)

F: RECOGNIZE UNCOMFORTABLE FEELINGS

FAVER starts with recognizing any uncomfortable feelings that stem from the patient's request. People are often adept at avoiding negative emotions, and physicians are no exception. In fact, they may have the added complication of being well-practiced at denying their own experience in service of others. Recognizing and not avoiding the discomfort of an inappropriate patient request is essential; it is the cue that you need to take a closer look at the situation.

To practice this, notice your emotional response while reading the following patient requests:

• “My oxycodone isn't working anymore. I need you to increase the dose.”

• “I want an MRI for my recurrent headaches.”

• “I have been summoned to jury duty. Can you give me a note so I don't have to go?”

• “Can you fill out this form so I can get an electric wheelchair?”

• “Can you write me a note so my dog can be a comfort animal?”

If you feel no discomfort from a patient's request, you are likely envisioning a context where the request is appropriate and you do not need to apply the rest of the FAVER framework. For instance, providing a medical excuse to a patient who would be physically incapable of sitting on a jury because of chronic back pain or severe anxiety would be good patient care. Or, if you have consulted with the psychologist who sees your patient for severe anxiety and determined that the presence of the patient's dog has increased her out-of-home function significantly, then approving a patient for a comfort animal might be perfectly appropriate.

In the absence of an appropriate context, however, discomfort develops and, with it, some characteristic thoughts:

• “I'm being taken advantage of.”

• “This patient is using me.”

• “I feel sorry for him.”

• “I feel uncomfortable saying no.”

• “He's going to get really mad.”

• “She is going to file a complaint about me if I do not give her what she wants.”

A: ANALYZE WHY YOU FEEL UNCOMFORTABLE

The second step of the FAVER approach is to analyze the thoughts that are leading to the discomfort. Your thoughts about the inappropriate request (e.g., prescribing opioids or back-dating a work excuse) can usually be mapped to one or both of the following:³

• Fulfilling this request would be poor medical care,

• Fulfilling this request would be illegal, dishonest, or against policy.

In most cases, you will quickly be able to identify the reason the patient's request feels inappropriate and uncomfortable to you.

V: VIEW THE PATIENT IN THE BEST POSSIBLE LIGHT

Several factors, including past experiences, time pressures, fatigue, burnout, and personality characteristics, may lead physicians to assume that the patient knows that what he or she is requesting is “wrong.” This assumption can compound negative feelings and complicate the interpersonal interaction further.

Viewing the patient in the best possible light is the antidote to further deterioration in difficult patient interactions. The goal is to actively assume that the patient does not know that what he or she is requesting is inappropriate. With this more neutral frame, the physician is in a position to respond to the patient more positively and more effectively and to feel more empowered as well.

It may help to remember that misunderstandings about medical issues are common and not usually personal. Remember also that certain behaviors can be expected with certain illnesses or situations. For instance, just as we expect people with diabetes to have high blood sugars, we might also expect people with substance dependence to lie or manipulate to get more of what they want. Viewing the patient negatively generally does not help the conversation. One might argue that assuming the patient is using you or trying to manipulate you helps guard against giving in to an inappropriate request. While that might be true for some patients, the cost to the relationship and to the physician's sense of well-being makes it an ineffective and unattractive option in most cases.

E: EXPLICITLY STATE WHY THE REQUEST IS INAPPROPRIATE

The next step is to explicitly state that the patient's request would be poor medical care, illegal, dishonest, or against policy. Physicians can couple this explicit statement with a brief explanation but need to avoid the following:

Lengthy explanations. When anxious, people tend to talk more. In these situations, the more physicians talk, the more they tend to move away from their original statement (e.g., “That would be poor medical care”), which creates room for debate. Not only is this type of debate exhausting and time consuming, but it also typically leads to the physician giving in or the patient feeling increasingly frustrated and misunderstood. If the physician stays on message, debating becomes a challenge because the patient is in the untenable position of arguing for poor care or for the physician to do something illegal, dishonest, or against policy.

Talking about your comfort level. A statement such as “I'm really not comfortable upping your dose of this medication” can anger patients who are not at all interested in your comfort when they view themselves as significantly more distressed. Alternatively, some may view your discomfort with the request as something to overcome by explaining their situation again or in greater detail.

Stating a position and then shifting that position. This compromises trust and the patient's confidence in the physician's decision. Additionally, it may provide space for debate.

Residents and new physicians often struggle with this because they do not have the experience, medical knowledge, and authority to establish a position or set limits unequivocally. More seasoned physicians can find themselves in a similar position, though. With an eye on the ticking clock during patient visits, they may not feel that they can take a moment to identify and set clear limits. It is better and more efficient in the long run to step out of the room, identify the limit, and then determine how to communicate it effectively to the patient.

Providing poor care or doing something dishonest, “just a little.” If opioid medications are not indicated for the patient's type of pain, giving the patient just a few or giving in just this time is akin to giving just a little bit of poor care. Similarly, saying, “I'm not supposed to write a work excuse for days already missed, but I'll do it this one time,” is a form of avoidance — a way to kick the can down the road a bit, which is counterproductive. This is especially true when you are covering for a colleague and he or she later has to undo your actions or take a different, less popular approach.

R: REESTABLISH RAPPORT

The final step of the FAVER approach is to reestablish rapport. Physicians don't need to have had their patients' experiences in order to empathize. If you have ever wanted something or thought you needed something and were not able to get it, you can tap into the feelings of frustration, fear, and powerlessness that your patients are likely experiencing. Making empathic statements such as “I know this is not what you wanted” or “I can see you are frustrated” acknowledges these feelings. Learning to accept a patient's negative emotions, rather than minimizing them or trying to fix them, is an essential skill for physicians.

Another strategy that can be helpful in reestablishing rapport is to use the phrase “I wish ... ” One of the tenets of motivational interviewing is to come alongside the patient and express things from the patient's point of view, at least in part, so he or she feels understood. This is hard to do when denying a patient's request, however, the phrase “I wish ... ” allows you to take the patient's side without giving in to the inappropriate request. For example, you could say, “I wish oxycodone were safe to use for your pain. I know you've said it works well for you. Unfortunately, it is not a safe treatment for your type of pain,” or “There are good reasons you don't want to go to jury duty. I wish I could write you an excuse. It would not be honest, though, so I can't.” It is important that the wish be genuine, which is more likely if you are actively viewing the patient in the best possible light.

POTENTIAL PATIENT RESPONSES

The FAVER technique may not feel easy at first, but it does get easier with practice and you may be surprised at how well patients respond. Most patients will accept your no, even if they feel disappointed. They are not getting what they want or think they need, and they will naturally be mildly unhappy. Occasionally, patients will have an angry reaction and may threaten to switch doctors or threaten to make a complaint against you. This is often a symptom of the disease and not a reflection of you or your treatment.

Less common but more concerning are patients whose actions appear threatening (using profane language, banging doors, name-calling, throwing papers, etc.) or patients who make overt threats to harm you or your staff. If your practice does not have a policy for responding to threatening behaviors, we recommend developing one. It should define consequences including patient dismissal and law enforcement, and should encourage physicians to take appropriate precautions to ensure their personal safety.

Although difficult interactions can often lead to a strengthening of the doctor-patient relationship, they can leave physicians feeling unsettled. Even when a physician does everything right, the outcome can feel bad. Often, physicians will conclude that the strategy or approach was ineffective and will want to abandon it for the future. In reality, a poor outcome might just be inevitable. For instance, some patients cannot be helped — not by you or not at this particular time. This is human nature and the nature of medicine. These patients may do better in the future or with another provider. Debriefing with a trusted colleague can help physicians recognize their role in these challenging encounters while also learning to not assume responsibility for their patients' emotional or behavioral reactions.

We expect that with use of the FAVER approach, physicians will feel empowered and energized by this simple, standard way to approach a relatively common and uncomfortable clinical scenario. Getting to no while preserving the relationship is not easy, but it is possible and well worth the effort.