How to Handle Patient Requests and Demands

Patients are consuming medical and health information as fast as it comes out and relaying it to their physicians as requests or demands for specific diagnostic tests, medications, devices, and treatment plans. Depending on how you say, “No,” they may go elsewhere, but “no” does not have to mean “goodbye.” Physicians can effectively communicate with patients and preserve treatment relationships while maintaining their professional standards and integrity. 

Explicit Requests Present Opportunities

Information, frustration, and knowledge of attractive competitors often motivate patients and caregivers to ask for tests, medications, surgeries and procedures, and other treatments by name. 

• • Physicians are no longer the gatekeepers of clinical information. There is an overwhelming amount of medical news, reports, statistics, and data, and numerous ways patients find, receive, and exchange it all. The information may boost patients’ and family members’ confidence to directly ask for what they believe they need or to go to the place they know they can get it.
      
  • The rise of chronic illnesses and the confusing relationship between medicine and business may leave patients and caregivers feeling hopeless about finding relief. Prolonged frustration can lead to tension and despair, but pain can give rise to desperate outbursts or hostility.
    
    
  • Patients are also reading about telehealth and receiving targeted ads based on their internet research. Some patients will skip the trip to their regular treating physician’s office and head straight to a telemedicine company, online pharmacy, or health system teleservice. Some may wait for their physician to say “no” before turning to online options.  

As the amount of and access to medical and health information increases, so will patient-initiated solicitations.  

Physicians who see explicit requests as a starting point for discussion may find that the dialogue increases patients’ trust and willingness to remain in the physicians’ practices. Ask questions about and consider why the patient or caregiver made the specific request. Their bid for a particular medication or treatment gives you valuable insight into their expectations. 

Explore the patient’s profession or occupation, interests and hobbies, and responsibilities for family and at home that may be related to the request. For instance, certain medications may be contraindicated if the patient is a commercial pilot, school bus driver, or a roofer.  

The patient may have requested something specific out of fear, as a result of television or online advertising, or because of a previous experience or a family member’s or coworker’s experience. Physicians might then ask how the request will help the patient meet her/his/their treatment goals and use the answers to form the basis of their response. 

Patients may choose to remain with their regular treating physicians but turn to other sources for an exact drug, test, or surgery. Hopefully, the regular physicians’ willingness to earnestly discuss the patients’ request means patients will be forthright and tell the physician about the drug, test, or surgery obtained elsewhere. 

Alternative Medical Care and Continuity  

Urgent care clinics and telemedicine companies and services compete with brick-and-mortar medical practices for short- and long-term patient relationships. They may be more convenient for patients but may not have considered communicating with a patient’s regular treating physician as part of their processes. 

Urgent Care Clinics 

Usually, patients must instruct urgent care clinics, and sometimes emergency departments (ED), to notify their regular treating physicians of test results, medications administered, and after-care instructions and prescriptions.  

Without a patient’s instruction, the communication may not occur, and the regular treating physician may see the patient in the office and not know the patient experienced a hypertensive crisis the previous week and is now taking a hydrochlorothiazide. Without the regular treating physician asking a direct question about a new medication or any trips to the ED or question on an office form about recent care, treatment, tests, medications, etc., the patient may not tell the physician about the ED visit and prescription. 

Telemedicine Companies and Services 

In 2023, Becker’s Hospital Review reported on over 280 telemedicine companies with a range of membership fees, same- and next-day appointments, and home delivery.  

• • Patients wanting GLP-1 injections or oral medication for weight loss delivered to their homes can schedule online evaluations by Nurx® prescribers to receive them. 
     
  • Through PlushCare®, patients can book same-day online appointments with prescribers and pick up a prescription for Keflex® or Symbicort® at a local pharmacy.
    
    
  • Patients interested in a sleep apnea consultation can go through LillyDirect® to virtually connect or set up an in-person appointment and possibly receive a prescription for Zepbound®.  

Telemedicine companies or the physicians or other prescribers on their panels may not automatically notify patients’ regular treating physicians about tests, treatment, and prescriptions. Patients may ask the telemedicine company or prescribing physician to share the information with their physician, go ahead and tell their physician about the telemedicine appointment and treatment, or forget or feel embarrassed or afraid to tell their physician. 

Keeping Track  

Generally, it is the patient’s responsibility to notify the physician of care and treatment by other physicians. When patients call the office and or send a message through a patient portal requesting a refill prescription, however, they may not think to tell the physician or office staff about new medications or other treatment provided by a telemedicine company or service. That information is important to the regular treating physician to prevent an adverse drug interaction.  

The mere act of updating a medication list at the patient’s next appointment may not trigger the patient’s memory. Physicians or their staff should directly ask patients about drugs, medications, and other treatments prescribed by other physicians or through telemedicine; add those questions to any form patients are asked to complete before an appointment; and add those questions to nurses’, medical assistants’, or other office staff’s documentation. 

Responding to Direct Requests and Demands 

Fostering Positive Patient Relationships 

Physicians should let patients, caregivers, and family members know there are limits to what is acceptable to say and what is suitable behavior to maintain the treatment relationship. For ideas, see  MICA’s Creating and Maintaining Positive Patient-Physician Relationships Guide and template patient code of conduct. 

Managing the Conversations 

Physicians might consider the following communication strategies to prevent the escalation of conflict. 

• Sincere conversations require making eye contact with the patient and caregiver.
  
  
• Patients and caregivers usually appreciate the physician’s recognition of the patient’s or caregiver’s emotions, concerns, requests, and/or expectations. 
  
  
• Positive reinforcement of the patient’s efforts and good choices up to this point and statements that show the physician’s interest in collaborating and making decisions as a team, without initially agreeing to the request or demand, invite the patient or caregiver to be open. Examples include the following:
  
  • “Your concern is valid.” 
    
    
  • “I agree with you on that point” or “You’re right about XYZ” or “I see your point about XYZ.”
    
    
  • “I appreciate all the work you are doing to XYZ123 and I can see why you might be hesitant about ABC456.”
• Explaining why the patient or caregiver should consider alternatives shows respect for their autonomy. 
  
  • Physicians appear highly responsive, well-informed, and compassionate by carefully correcting any misinformation or misinterpretations while acknowledging the patient’s active participation in their care and desire to make decisions together.
    
    
  • An example situation is the patient saying she/he/they need(s) magnetic resonance imaging (MRI) for a brain tumor after learning of a first cousin with a brain tumor.  
    • Instead of immediately saying, “No,” the physician might say, “An MRI is an option but here’s something I think we should do first,” or “An MRI is one way to check but there are risks involved and I have a less risky idea.” 
    • Another approach may be, “I want to go over some options. The options are not what you’ve asked for but may help you feel better faster.” 
  • Another example situation is the patient who previously experienced a placental abruption asking her established OBGYN to co-treat her and remain available during a home birth with a lay midwife who is not part of the OBGYN’s group practice.
    
    • The physician might respond, “I can see you are excited to be working with your midwife and delivering your baby in the comfort of your own home and surrounded by your family and friends. I’d like to go over the risks of a homebirth to your and the baby’s health, and then talk about my role should you decide to move forward with the idea.” 
      
      
    • Another approach may be, “There are a lot of positives about delivering your baby at home and I want to make sure you know what all of your options are. I’ll also explain my role in those options.” 
• Discussing the risks and benefits of and the alternatives to the patient’s request is part of any informed consent or informed refusal process. 

• Inviting the patient or caregiver to call and set up subsequent appointments demonstrates the physician’s commitment to the relationship. 

These strategies, and the related skills, should be part of the evolution of physicians roles from imparting all clinical information to having intentional and productive conversations with patients.  

Documenting the Conversations 

Physicians should document at least the following: 

• • The substance of the patient’s or caregiver’s request or demand (or quote the patient);
    
    
  • The patient’s or caregiver’s reason for the request or demand;
    
    
  • The patient’s or caregiver’s points and your discussion points;
    
    
  • An explanation of the risks and benefits of the request or demand, alternatives to the request, and the risks and benefits of the alternatives;
    
    
  • Whether the request is contraindicated in the medical or pharmaceutical literature;
    
    
  • The patient’s or caregiver’s decision or response; and
    
    
  • The next steps.

Should the physician and patient decide to part ways, the physician should follow the risk management recommendations in MICA’s Terminating the Physician-Patient Relationship Guide and template letters. 

Following Your Education, Training, and Experience 

A patient’s request or demand for a specific test, drug, procedure, or treatment may not align with the legal standard of medical care. The standard of care in most states is what a reasonable prudent physician with the same or similar education, training, and experience, would do in the same or similar circumstances. Sometimes saying “no” is the standard of care.