Getting to “No”

Abstract

Background Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness. Methods Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test. Results Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P=.001). Conclusions Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.

Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

“… 57 For example, because we know that patient requests influence providers’ discussions and recommendations, we may be able to develop techniques for providers to address patient requests instead of offering services that are likely to harm patients. 58 Based on our findings, these approaches may need to differ for prostate cancer and CRC screening. For instance, given our findings that providers’ perceive guidelines as influential, but not associated with lowest-value screening recommendations, efforts may need to focus on increasing providers’ agreement with and their self-efficacy to implement guidelines.…”

Nurse Practitioners' Use of Communication Techniques: Results of a Maryland Oral Health Literacy Survey

“…A patient-centered provider bears the responsibilities of helping ensure patients have accurate, accessible and usable information, as well as the support needed to make decisions and participate in their own care [ 28 ]. Patient-centered communication is associated positively with patient satisfaction, increased adherence to treatment plans, and improved health [ 27 , 29 – 31 ]. A qualitative analysis of a convenience sample of NP-patient encounter transcripts revealed that approximately 30% of NPs used the patient-centered communication technique of “information-giving”, while 70% used a provider-centered communication method [ 26 ].…”

Development of the Chronic Pain Coding System (CPCS) for Characterizing Patient-Clinician Discussions About Chronic Pain and Opioids

“…70 On the other hand, one recent study found that patients displayed significantly greater emotional arousal during discussions of pain compared to discussions of other topics. 71 Another possible explanation for our findings related to resistance / disagreement is that strong social pressures to maintain polite discourse 20 and minimize disagreement 72, 73 during clinic visits make overt conflict rare even for contentious topics such as opioids.…”