How Do Physicians Say “No” to Patients

A relatively recent phenomenon in medical care is direct-to-consumer advertising, which seeks to influence a patient to request certain services or products from their physician.  This is exacerbated by the rise of social networking, which may also influence patient demand.  In earlier eras, the physician would determine what he believed would work best for the patient based on his or her experience, training, knowledge, peer advice and to some extent, detailing and continuing education sponsored by medical product or equipment companies.   An article published in the Archives of Internal Medicine explores strategies physicians use to dissuade patients from pursuing unneeded medical products or services.  (Archives article) In about 10% of visits, patients request medication.

When reacting to a patient request, physicians have several considerations to balance.  One is their ethical duty to do no harm and maximize patient benefit, as well as respecting patient autonomy.  They must exercise caution when prescribing new treatments or products or those of uncertain benefit.  And they are increasingly expected to be aware of cost considerations.  In this study, the doctors were presented with a trained pseudo-patient who complained of depression symptoms, and many of whom were to expressly ask for an anti-depressant.  The physicians agreed to participate in the study, but did not know which were the pseudo-patients.

Physicians complied with about 44% of the requests.  In the cases where they rejected it, three primary strategies were used:  one labeled as patient-perspective based; one as biomedically-based and one as outright rejection.  About 63% of the rejections fell in the first category, 31% in the second and only 6% in the last.  The pseudo-patients, who did not know the purpose of the study, reported much higher satisfaction with visits where the rejection was patient-perspective based, which typically involved more conversation and discussion with the patient about their symptoms, the reasons for them, the reason for request for medication and more overt discussion by the physician of his or her thinking.

This is a useful body of research and the results from this and future studies will hopefully be incorporated into medical school curriculum and doctors explicitly trained on dealing with these situations.  It would also help if DTC advertising, which has little justification as improving patient care, were limited, as well as other efforts by product companies to influence patients’ behavior.