How to Handle Patient Demands

Massive electronic communication networks, heavy advertising by pharmaceutical companies, and the availability of medical research online motivate patients to request specific medications, tests, procedures, and referrals. Research shows physicians and other healthcare practitioners often agree to the requests, even when their professional judgment tells them otherwise. Imagine the following scenarios.

Scenario 1: A mother brings her 14 year-old daughter to the emergency room on a Saturday afternoon. The daughter is suffering from a severe headache that kept her from participating in her team’s softball tournament earlier that day. Her mom reports that this is the fourth time in six months that her daughter has had such a debilitating headache, and is concerned that it could be something serious. She requests that her daughter undergo an MRI while at the hospital. You acknowledge the request and assure her that is a possibility if clinically indicated, but that you would like to take a detailed history first.

Upon doing so, you learn that the daughter’s headaches seem to happen around the time she begins menstruating each month. You explain to the mother and daughter that this is a common phenomenon, recommend that she take over the counter pain medication, and follow-up with her pediatrician. The mother is insistent on an MRI to rule out the worst-case scenario. You must make a choice between holding firm on what you know is the right clinical decision or giving in to keep the patient’s anxious family member from getting angry.

Scenario 2: You are an internal medicine physician with an after-hours line patients can call if there is an urgent situation. You have a patient who frequently calls with questions and concerns that could wait for an office visit. You were not too concerned about it, though, until he called twice over the last several months asking for an opioid pain medication for back pain which traditionally has responded well to OTC NSAIDs.

You obliged the first two times with a limited supply, but he has called again, and you are concerned that this is pill-seeking behavior. You also do not want to upset the patient or ignore legitimate pain. You must decide whether to acquiesce to keep the peace or tell him he must be seen in-person so you can come up with a treatment plan.

What would you do in these, or similar, patient encounters?

Half the respondents to a 2014 state medical society survey said they have written unnecessary but patient-requested prescriptions and orders for antibiotics, opioids, tests, procedures, and hospital admissions to avoid conflict and ensure better patient satisfaction scores.¹ In fact, a 2018 study found that patient satisfaction is demonstrably impacted by a physician’s denial of certain types of requests.² This suggests that physicians and other healthcare practitioners may benefit from education on how to effectively deal with inappropriate requests and rely on their education, training, and experience to make clinical decisions even when they feel pressured to acquiesce to patient demands.

Evidence of Acquiescence

Through their desire to heal, comfort, and preserve patient relationships, physicians and other healthcare professionals may yield to patients’ requests. In one study, researchers produced two sets of clinical videos: an undiagnosed patient with symptoms suggesting sciatica and a patient diagnosed with chronic osteoarthritis of the knee.³ Actively practicing physicians developed the scenarios based on actual patient encounters.

The researchers predicted that multiple videos utilizing varied patients of differing socioeconomic status, gender, race/ethnicity, and request styles (assertive or passive) and physicians of differing age, gender, and clinical experience would account for variances. The patients had different professions and occupations: truck driver, salesperson, janitor, and lawyer. Independent primary care physicians reviewed the clinical content.

Half of the sciatica patients requested oxycodone and half of the osteoarthritis patients requested Celebrex. The way the patient worded the medication request was essentially the same. The physicians watched pairs of videos, first the passive request and then the active request.

PASSIVE Request: The osteoarthritis patients told the physician they saw a television advertisement for Celebrex and that a coworker takes Celebrex and believes it works.

ACTIVE Request: The sciatica patients told the physician their spouse had some left-over oxycodone, the patient took one, and the patient was amazed at the relief.

Experienced primary care physicians from six states watched the videos and completed a survey of management of the patient and the prescribing decision.

Prescribing decisions where suspected sciatica patient PASSIVELY requested oxycodone:

% Physicians Prescribing	Physicians’ Choice of Medication
1%	Oxycodone
29%	Strong narcotic4
26%	Weak narcotic5
64.6%	NSAID
43%	No narcotic

 

Prescribing decisions following suspected sciatica patient’s ACTIVE request for oxycodone:

% Physicians Prescribing	Physicians' Choice of Medication
19.8%	Oxycodone
56.2%	Strong narcotic6
12.5%	Weak narcotic7
56.2%	NSAID
34%	No narcotic

 

The researchers chose narcotics for the study because they are usually effective for short-term use but generally not recommended for sciatica and possibly contraindicated for a patient whose occupation is driving. After watching the patient-requesting-oxycodone video, most study participants prescribed a “strong narcotic” and were less likely to prescribe a “weak narcotic.”

Prescribing decisions where osteoarthritis patient PASSIVELY requested Celebrex:

% Physicians Prescribing	Physicians' Choice of Medication
24%	Celebrex
40.6%	Narcotic
51%	Non-selective NSAID
34.4%	No NSAID

 

Prescribing decisions following osteoarthritis patient’s ACTIVE request for Celebrex:

% Physicians Prescribing	Physicians' Choice of Medication
53.1%	Celebrex
30.2%	Narcotic
33.3%	Non-Selective NSAID
17.7%	No NSAID

 

The researchers chose Celebrex for the study as a more expensive, but not therapeutically better medication than non-selective Cox-2 inhibitors. Study participants were more likely to prescribe Celebrex following the osteoarthritis patients’ requests and were less likely to choose another NSAID.

The patient’s race/ethnicity, gender, socioeconomic status, and request style, and the study participants’ gender and experience level did not appear to affect the physicians’ decisions. The researchers concluded that patients’ requests alone influenced the physicians’ choice of medication. The style of the request, passive or active, seemed to have the greatest influence over the physicians’ decisions.

Active requests for a strong narcotic, Oxycodone, or Celebrex were almost always successful but other covariances were as influential as the request style. The higher the percentage of the physician’s income was dependent on third party payor quality of care measures and number of patient visits per the week, the more likely they would acquiesce. The participant’s level of personal responsibility for the financial success of the practice also seemed to result in compliance with patient requests. Perceptions that administrative issues affected clinical decisions and belief that their compensation was unfair appeared to correlate with denial of the requests.

The Takeaway

The results of the study reveal an opportunity for physicians and other healthcare professionals to more effectively respond to requests for opioids and specific medications, tests, and referrals and to improve communication. The following professional liability risk strategies will help formulate a respectful and genuine response.

• Acknowledge the patient’s emotions, concerns, requests, and/or expectations.
  
  
• Consider why the patient made the specific request. The patient may have requested something specific out of fear, as a result of television or online advertising, or because of a family member’s or coworker’s experience. Physicians should ask how the request will help the patient meet his/her treatment goals. The patient’s answers should help form the basis of the physician’s response.
  
  
• Explore the patient’s occupation, hobbies, and family responsibilities related to requested alternative medications. For instance, certain medications may be contraindicated if the patient is a commercial driver, uses woodworking tools, or operates heavy or dangerous machinery.
  
  
• Say “no” with an explanation. When a patient says s/he needs a magnetic resonance imaging (MRI) for a brain tumor, Dr. Chesanow, an internist writing in a Medscape article, suggests not immediately saying, “No.” Instead he says, “Well, an MRI is an option but let me tell you what I think we should do or what the best option is for you” or, “Okay we can consider your request, but let me tell you what I think.” The internist’s other approaches are, “Well, we could do what you want but let me tell you why we shouldn’t,” and, “Let me offer some treatment options that aren’t what you asked for and tell you how we can get you feeling better so that you can [mow your lawn]."⁸
  
  
• Encourage and positively reinforce the patient’s efforts and good choices so far. Examples include, “Your concern is valid,” “I agree with you,” “I see your point,” and “You’re right.” Such statements indicate collaboration and shared decision-making without agreeing to the patient’s request.
  
  
• Discuss the risks and benefits of and the alternatives to the patient’s request.
  
  
• Document the request; the patient’s reason for the request; the discussion and patient’s acknowledgment of risks, benefits and alternatives; whether the request is or is not contraindicated; and the patient’s decision or response.

Saying no and having it accepted is a skill which can be developed. Learning to say no using the FAVER approach takes five steps.⁹ The watchful waiting, or wait and see approach, is another way to skillfully say no to an immediate request for something specific the physician does not believe is indicated.¹⁰ No matter the method used, learning to say no takes practice.

If you have questions about how to handle patient requests or would like to schedule a medical professional liability risk consultation, please contact our Risk Consultants directly at 800-705-0538 or rm_info@mica-insurance.com.  

<sup>[1] Impact of patient satisfaction ratings on physicians and clinical care, Patient Prefer Adherence, 2014;8:437-46, Last accessed September 13, 2023, at Impact of patient satisfaction ratings on physicians and clinical care - PMC (nih.gov).

[2] Jerant A, Fenton JJ, Kravitz RL, et al. Association of Clinician Denial of Patient Requests With Patient Satisfaction. JAMA Intern Med. 2018;178(1):85–91. Last accessed September 13, 2023, at Association of Clinician Denial of Patient Requests With Patient Satisfaction | Health Care Quality | JAMA Internal Medicine | JAMA Network.</sup>

<sup>[3] McKinlay, J., Trachtenburg, F., Marceau, L., Katz, J., Fischer, M., Effects of patient medication requests on physician prescribing behavior: results of a factorial experiment, Med. Care. 2014 April; 52(4):294-299.

[4] Hydrocodone, oxycodone, vicoprofen, roxicet, percocet

[5] Codeine, tramadol, ultracet, propoxyphene napsylate

[6] Hydrocodone, oxycodone, vicoprofen, roxicet, percocet</sup>

^{[7] Codeine, tramadol, ultracet, propoxyphene napsylate}

^{[8] Neil Chesanow. 10 Ways to Say No to Patients – and Still Keep them Smiling – Medscape – Feb. 17, 2016. Last accessed September 13, 2023, at https://www.medscape.com/viewarticle/854509_2?&icd=login_success_email_match_fpf.}

^{[9] Getting to no: how to respond to inappropriate patient requests, Last accessed September 13, 2023, at https://www.aafp.org/pubs/fpm/issues/2018/0100/p25.html.}

^{[10] May, L., Franks, P., Jerant, A. , Fenton, J., Watchful waiting and diagnostic testing, J. Am. Board Fam. Med. 2016; 29:710-717.}