How to Say No to Patients, Ethically

Scenario

You are evaluating a 54-year-old woman who recently moved to your community from out of state. The patient found your name through an Internet search. Her chief complaint is right ear pain of three months’ duration, which she believes is an “ear infection.” She is requesting antibiotics for the alleged infection, which she claims is preventing her from sleeping at night due to the pain. Her past medical history is significant for type II diabetes, hypothyroidism, and elevated triglycerides, as well as two motor vehicle accidents in the past, for which she wore a cervical collar for pain. The patient states she is a non-smoker and non-drinker, and denies drug use. Current medications include levothyroxine, metformin, and rovustatin.

The complete head and neck examination, including microscopic otoscopy and flexible fiberoptic nasopharyngolaryngoscopy, are within normal limits, save for some discomfort when palpating the posterior neck. Dental occlusion is Class I, and there is no crepitus or pain at the temporal-mandibular joint. Your working diagnosis is cervicalgia as a result of previous trauma, with referred pain to the ear. As you explain your findings and presumptive diagnosis to the patient, she quickly reiterates that she feels her pain is due to an ear infection, and what she really needs is an antibiotic, and by the way, could you refill her thyroid, diabetic, and statin medications since she has been without them for the past three weeks due to her move to this community. She states, “I can’t live with this infection, and without my medications.” Additionally, she mentions that she came to see you because you had excellent patient satisfaction scores on the Internet.

How should you deal with her requests?

Discussion

Saying no to a patient’s treatment request(s) is often complicated and can be laden with confounding issues. Most importantly, physicians must follow professional clinical care guidelines and properly balance the fundamentals of medical ethics: patient autonomy, beneficence, non-maleficence, and social justice. It is not uncommon for several of the ethical principles to be in conflict for a given situation, and the preferred mechanism of shared decision-making with the patient may not always be feasible.

Professional responsibility requires discernment in an analysis of the physical, mental, emotional, and social aspects of the patient’s condition, leading to the development of an appropriate management plan for the patient. This initial analysis must be performed in a relatively short period of time, and includes pertinent questioning, active listening, and appropriate examination. Health is not just a physical condition, but also involves the patient’s perception of illness and wellness, as well as their personal emotional status and coping mechanisms. Such non-physical factors become more obvious and increasingly important in patient care as a physician gains experience over years of practice.

Patient Satisfaction Scores

Physician information on the Internet has brought both positive and negative effects to the practice of medicine—positive in the sense that patients have access to important information about a physician’s education and training, contact information, forms to be filled out, and secure patient portals; negative in the sense that dissatisfied patients may post information online that may or may not be truthful, and that could have a deleterious effect on the physician’s reputation. Of course, positive feedback about the care provided is appreciated, but the emphasis placed on “patient satisfaction scores” could potentially cause a physician to treat a patient in a manner inconsistent with generally accepted clinical guidelines in order to avoid a negative satisfaction score. Additionally, for some physicians, compensation may be dependent, in part, on patient satisfaction scores, which may result in an unconscious or conscious bias toward treating the patient according to their requests rather than based on excellent medical judgment, clinical guidelines, evidence-based medicine, and experience.