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.

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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.

It can be a fine line for a physician to navigate, as many everyday ethical challenges may involve low-risk clinical decision making. The value of patient satisfaction scores and their impact on physician clinical decision making are currently under discussion in the medical ethics community, as concern rises regarding what ultimate effect they may have on patient care.

Maintaining the Physician–Patient Relationship

There are many reasons why physicians may find it hard to “say no” to a patient. Primarily, a physician has a sense of responsibility to the patient and values a positive patient–physician relationship. There are enough challenges these days to this relationship without mishandling a disagreement regarding patient requests versus physician judgment, especially if the request has a low risk:benefit ratio. In an established relationship, discussions about patient requests tend to be a bit easier than those occurring with a new patient.

“Demanding” patients encompass a range of severity; the easiest may require a simple explanatory discussion, while the hardest may pose significant risks to the patient and significant challenges to the physician. There are a number of generally accepted recommendations for physicians in dealing with patient demands: maintaining a calm and understanding demeanor, listening actively for underlying concerns, observing patient body language and facial expressions, delineating the boundaries of the physician’s clinical care, providing positive reassurance, and explaining what the physician feels is in the best interest of the patient. It is particularly important to investigate the “unstated” concerns that may be driving the patient’s demands and that may reflect underlying non-organic difficulties with which the patient is dealing. Human beings are complex, and the experienced physician will understand the potential impact of the psyche on wellness/illness and human behavior.

In addition to reasons listed above, physicians may find it difficult to “say no” to patient requests out of a sense of responsibility to help the patient, the desire to avoid a confrontation, and the question “what harm could it do?” The latter depends a great deal on just what it is the patient is requesting, and whether the requests are concerning or inappropriate for the physician’s particular practice or could clearly lead to additional requests of more serious concern. Even with acknowledgement of clinical practice guidelines, some requests are not “clear-cut,” and may fall along the “gray line” of propriety. Further discussion can be quite helpful.

Saying No

In this particular scenario, the patient is requesting a medication that is clearly not indicated (antibiotic) based on the history and clinical examination. The otolaryngologist can explain to the patient that there is no evidence of an infection, and can review the neuroanatomy of cervical afferent nerves that may be compromised due to cervical spine disease secondary to trauma. A clear and concise explanation of the otolaryngologist’s premises, along with a recommendation for further imaging and consultant evaluation, using terminology understandable by the patient, will be quite helpful. All potential etiologies for otalgia should be considered, and further diagnostic testing predicated on likelihood of occurrence. The patient should be allowed to ask questions—just not for an inordinate amount of time—and be reassured that the otolaryngologist will work with her to identify the etiology and refer the patient to the appropriate provider if the cause is not within the scope of otolaryngology-head and neck surgery.

It is also important to be cognizant that the patient might be concerned about other issues, such as the presence of a tumor or malignancy, and open-ended questions might elicit such concerns. The otolaryngologist should provide a cogent explanation for denying the antibiotic request so that the patient does not feel ignored.

The other requests regarding filling her general medical prescriptions are normally not a part of the services of an otolaryngologist, but rather of a primary care physician. The responsibility for prescribing medications such as statins, diabetic medications, and thyroid drugs is typically not a part of an otolaryngologist’s practice. It is better to politely decline to do so, explaining the different responsibilities of the specialist versus primary care, and offering to arrange for the patient to be seen by a primary care physician as soon as feasible. The otolaryngologist should be understanding of the patient’s dilemma, but also firm about not prescribing those medications for patients who require the care of a generalist physician.

“Saying no” to a patient does not mean that the patient–physician relationship will become negative or counterproductive. It depends upon how the otolaryngologist conveys the information to the patient and works to help the patient understand the situation. If the patient feels the otolaryngologist is honest and has her best interests in mind, as well as having presented a plan for further evaluation and monitoring of her ear pain and a referral to a primary care physician, it is likely she will become a valued patient. In this particular situation, non-maleficence outweighs patient self-determination (autonomy), and the end result will likely be beneficial for the patient—and for the otolaryngologist.

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Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.