Case Scenario

I recently quit my full-time practice in a wealthy suburb. Now, as I look for a new practice, I am anxious to avoid the pitfalls of my recent experience. My problem was this: I felt that too many of my patients came to me with unreasonable demands and seemed to think my job was to write the referrals they wanted.

More than once, for example, a patient with knee pain demanded a magnetic resonance imaging (MRI) test. Although I explained that the pain could best be addressed by resting the affected knee and altering running or bicycling ergonomics, this kind of advice rarely seemed to be enough for my patients. At their jobs, my patients were used to aggressive, confrontational relationships, and they continuously challenged me into arguments.

Patients often arrived at the office armed with complex and marginal information from the Internet that was inconsistent with standards of care. Sometimes, if the patient's spouse was enrolled in a separate insurance plan, the patient moved to a second “primary” provider through that plan to obtain the desired referral. Even if I work with a different kind of patient population in my new practice, I would like to know how to handle patients who insist on having unnecessary and expensive diagnostic studies performed or request treatments of dubious benefit.

Commentary

Receiving requests for “unnecessary tests” is a common experience in primary care. The definition of “unnecessary” will vary from physician to physician; yet, this issue is sure to confront most physicians. It is critical to develop a strategy to deal with these situations; otherwise, the physician is left feeling as described in the case scenario above—someone whose job is simply to write the referrals dictated by the patient.

The first step in addressing unnecessary demands is to ascertain the patient's needs. Frequently, patients express the conclusion they have arrived at (i.e., “I need a diagnostic test”) rather than the route through which they arrived at their conclusion. What is the patient's underlying concern? Has the patient received an adequate explanation for the medical problem? Is the diagnosis understood by the patient? Is more patient education necessary? Thus, as in most medical practice, the first step is to listen carefully.

Allow the patient to fully tell the story, with minimal interruptions. Ask the patient for details: “I understand you are here because you want an MRI of your knee; I'd like to understand how you reached that decision.” Physicians are trained to rapidly assess a situation and make a determination. Most of us do this within seconds of encountering a patient. Regardless of whether the patient is ill or not, we make a decision. It is subsequently quite easy to move quickly to autopilot. The physician's inner language sounds something like this: “I already have the diagnosis. I already know what I am going to do.” When one feels irked by a patient's request or demeanor, it is best to transfer this feeling to the signal to slow down. Give the patient more time. Although it may be opposite to our natural inclination, these are the patients worth drawing out, getting to know better, and understanding their values and preferred mode of communication.

The physician described the feeling that patients were challenging and argumentative. Entering into an argument will fulfill the patient's expectation. Instead, consider rolling with the resistance.¹ This can be accomplished in a number of ways. Consider agreeing with the patient: “Perhaps doctors are underdiagnosing knee injuries; let me share with you my strategy for evaluating knees.” Make sure to include in your explanation at what point during your work-up the desired test would be ordered. Or, reflect on the patient's words in a calm tone: “You can get this test from your wife's doctor as well as from me.”

Once you believe you really understand the patient's story and concern, summarize these points aloud for the patient. This allows the patient to correct or amplify. It also allows the patient the experience of being heard and understood. An attempt to reflect the emotion behind the request is important: “It sounds incredibly frustrating to be laid up with knee pain for so long,” or, “You sound like you are really afraid there is a major problem with your knee.” Patients will usually correct you if you miss their feeling: “I'm not frustrated; I'm angry.”

In the case described, the patient accrues little risk by having an MRI. This is not always true when patients request tests. For example, an unnecessary mammogram that yields a false-positive result will be followed up with a biopsy that entails significant risk. Furthermore, women with benign biopsies experience higher levels of anxiety up to 18 months after the procedure.²

A similar controversy revolves around prostate-specific antigen (PSA) testing.³ This test requires discussion with the patient and an understanding of the risks involved. Depending on the outcome of the discussion and the physician's opinion, situations will occur when the physician cannot fulfill the patient's request. When this occurs, the physician's style in saying no is critical.⁴ I recommend that physicians develop an introduction (e.g., “I know this is something you were really hoping I could help you with,” or, “This is really difficult for me to say.”). Then, the physician can briefly give his or her rationale and express empathy if possible.

Some physicians may feel they have to share too much authority with patients. Not all physicians (or patients) desire a partnership. Some physicians resent patients who arrive with articles and information from the Internet. Yet, better-educated patients are becoming the norm in this information age. It is the physician's responsibility to share information about how and why decisions are made and the patient's right to receive it.

Finally, some patients have narcissistic styles and come across sounding “entitled.” These patients prove challenging for even the most sophisticated communicator. Firm boundaries are the rule here. Make explicit ground rules and be absolutely clear to the patient what can be expected, then follow your own rules to the letter.

In summary: listen (more than you think you need to), avoid argumentation, explain your rationale, pay attention to the way you say no, and, if all else fails, breathe deeply and start over.