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Getting to "No" Your Patients


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As we encourage patients to be more engaged, we may also see more who go beyond assertive to demanding care unsupported by good clinical judgment. Understandably, physicians worry that saying “no” to a patient increases their risk of being disliked, dismissed, or even sued for medical malpractice. But the right mix of clinical judgment, bedside manner, and documentation can help take the “maybe” out of saying no to a request for unnecessary—or unsafe—testing or treatment.

More transparency in health care means patients are more aware of options for screening, testing, procedures, and medications—often via direct campaigns. The advent of social media further expands the spread of both legitimate and untrustworthy health care information. Thus, an anxious or desperate patient may ask for something about which they have heard or read, e.g., an MRI after a negative mammogram, a better drug for acid reflux, a cesarean section scheduled for convenience, an experimental procedure “like on House, MD.” In the face of such requests, maintaining an effective patient relationship, practicing appropriate care, and heeding the pressure to control cost—can be a real challenge.

If your clinical judgment is to say no, then saying yes—because it is easier, faster, less of a hassle—may pose hazards to both you and your patient. Even relatively benign procedures can carry the risk of unintended consequences. For example: changing a medication regimen can destabilize a patient's health; a “convenience” delivery before 39-weeks gestation may violate clinical guidelines (or hospital policy); experimental procedures (even those from the real world) are the purview of those physicians working to perfect a new technique with patients selected via exacting criteria—not just foot stomping.

Explaining to a patient the reasons behind “no” takes time and patience. But thoughtfully discussing and documenting such requests will improve your chances of maintaining good rapport and leave you less vulnerable to an allegation of malpractice than if your refusal is curt, dismissive, or poorly documented. Listening with respect to what the patient's aunt or neighbor or favorite blogger has suggested gives you an opportunity to respond with your own expertise and reasoning. Such conversations also provide an opportunity to elicit suppressed concerns and a chance to assure the patient that he or she is part of the process. Noting in the record a) what the patient requested b) your rationale for denying that request, and c) what you recommended instead, gives you, the patient, and subsequent providers context for future requests and decision making.

Of course, crossing your t’s and dotting your i’s after saying no doesn’t mean a disgruntled patient won’t pursue a complaint—that’s beyond your control. But if the complaint is in the form of a malpractice allegation, then your medical professional liability insurer will have such claims assessed by medical experts in your specialty. Their opinion will be based on their own experience, the prevailing standard of care, and your notes. To that end, a properly documented decision based on solid clinical judgment and matched by the practice of your peers is the best support for your decision to say no. 


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July 27, 2012
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