to the editor: I must take exception with the Curbside Consultation in the February 1, 2004, issue of American Family Physician.¹ The authors confuse the terms “needs” and “wants,” and in doing so create a situation where patient expectations trump sound medical decision-making. In the case presented, the authors state: “Although the physician wants to perform a complete diabetes work-up, it would be incongruent with the needs of this patient.” I disagree wholeheartedly. What the patient needs first and foremost is improved blood glucose control, but also a complete examination to look for already existing complications of diabetes, laboratory work including chemistries, a lipid panel, A1C levels, urine test for microalbuminuria, dilated funduscopic examination, diabetes education, and routine follow-up. What the patient wants is a one-stop, quick fix including a prescription for medication that may have possible adverse effects.

Physicians are routinely faced with patients who “need” antibiotics for a two-day viral upper respiratory infection, cortisone injections for benign rashes, and prescriptions for the latest drug they saw advertised on television. As physicians, we cannot give in to these requests, or we will be guilty of not providing quality care, opening ourselves to medical liability and a lack of credibility in the community. When faced with such patients, physicians have the responsibility to fully inform the patient that their request is outside usual practice, and then document this discussion. Physicians should not be made to feel that they must accommodate these patient requests.

in reply : Dr. Eady presents an important reflection on our article.¹ We fully agree with her that “as physicians, we cannot give in to these requests” for inappropriate treatments such as antibiotics for viral infections and cortisone injections for benign rashes. However, when interacting with patients whose frame of reference for chronic disease is different from our own, we should work to negotiate with the patient and the family to meet the patient’s needs. In the original article,¹ the patient wanted a quick fix for new-onset diabetes. Obviously, diabetes is not amenable to a quick fix, but one could initiate some treatment to help with symptoms and blood glucose control without ordering a battery of tests and consults. Our intent was not to suggest that physicians should acquiesce to every patient request, but to acknowledge that there is room to negotiate a plan of diagnosis and treatment (particularly when dealing with patients from a different culture) that may be beneficial for the patient and satisfying for the physician. This is offered as a challenging, but acceptable, alternative to refusing care for patients.