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Complementary and
Alternative Medicine:
••Fall 2002/Vol. 6, No. 4

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Health Systems


CPC Corner:
How to Say No
By Edward Wang, MD; Andrew Golden, MD; Pamela J Butterworth, MA, MHRD

Introduction

When patients demand medication, tests, or something not medically indicated, several things may go through your mind:

  • Why is this happening to me?
  • Until now, I thought I was having a good day.
  • Who does the patient think I am, their medical waiter?
  • No. No. No!

The usual scenario might find you repeating phrases such as the following:

  • "No, you don't really need this, because "
  • "There is no reason to order this [test, procedure] or to either prescribe or take this [medication]."

As most clinicians know, taking this approach does not always work. Well trained as we are in the medical sciences, practiced as we are in the art of healing, and wanting as we do to please our patients, we are often unready to say no to patients when they want a particular prescription or test, even if it is unwarranted. What strategies can we use to address these frequently uncomfortable situations?

Establishing Rapport

Before a patient listens to your advice, a good clinician-patient relationship must be established. The trust placed by patients in their clinicians must be established up front. Often, however, this relationship must be established in unfamiliar surroundings, such as the emergency department or urgent care department. In these busy areas, where each patient-clinician interaction is very brief, establishing rapport--the first of the Four Habits of Highly Effective Clinicians1--is particularly important because it sets the tone of the interaction, during which the patient must develop the trust essential for hearing (and accepting) medical information and adhering to therapeutic regimens. To establish rapport with the patient, the clinician may say something personal or use "small talk" upon entering the examination room. For example, if the clinician knows that the patient has been waiting in the examination room, the clinician may say to the patient, "I am sorry about the wait."

Elicit the Patient's Perspective

A patient's own explanation of his or her illness is called the Explanatory Model1 and is an important consideration in delivering effective medical care. The ability to discover the patient's perspective regarding his or her medical condition is a crucial skill for clinicians because it may prevent or defuse potential conflict with the patient, who usually has a personal reason for requesting a particular drug or medical procedure. The reason may seem illogical to the clinician, but it always deserves to be heard. A patient may, for example, be afraid of catching pneumonia or being diagnosed with incurable cancer if a symptom is left unattended for too long. A patient may be reluctant or unable to express his or her theory and fear about the symptom. Most of the time, the patient wants (and expects) the clinician to relieve symptoms or address the patient's fear. This expectation must be met before the patient can obtain satisfaction; indeed, the emotional needs of the patient must be addressed before any treatment is given. You must listen carefully for the psychological reason why the patient has come to see you. Only then can effective reassurance be given. Questions such as "What do you think is going on?" or "Are you afraid of anything in particular?" may allow the patient to reflect and express his or her own perspective.

Empathy

Empathy is a skill that allows a clinician not only to understand patients (ie, by identifying their emotions) but to effectively reassure them (ie, by verbalizing this understanding). By expressing this understanding verbally, clinicians can show that they care for their patients' well-being and thus promote patients' trust. For example, a clinician may say, "This cold must have been terrible for you!" or "Your headaches must have scared you! Since your dad had a brain tumor, you must be thinking that maybe you have the same illness."

Acknowledging Difficulties, Being Flexible, and Setting Boundaries

When disagreement or dissatisfaction--expressed verbally or nonverbally--develops while interviewing the patient or while administering treatment, clinicians sense this difficulty but often do not address it. A clinician may have many reasons for refusing to acknowledge conflicts. "I don't have enough time" or "I don't want to get into an argument" are examples of these reasons. However, the conflicts will probably resurface later: The patient may initiate another office visit or develop distrust of the clinician or medical care system. Often, if you acknowledge the difficulty internally to yourself and verbally to the patient, that patient will take the first step toward negotiating a helpful compromise.2 One such statement acknowledging a difficult situation could be, "I can see that we are having some difficulty here in agreeing on the treatment plan."

In saying no, your flexibility is at issue. Therefore, when a conflict occurs, be conscious of whether you want more flexibility or whether you must set firm boundaries.2

Invest in the End

Clinicians are generally more able to identify problems than to communicate findings. Patients who request antibiotic drugs or diagnostic tests are usually asking for symptom relief: They may request medication to cure a cold or may seek reassurance in the form of negative test results (eg, requesting magnetic resonance imaging [MRI] to prove that a headache is not being caused by a brain tumor). These initial reasons should be addressed, and the treatment goals formulated by the end of the visit should be consistent with the reason that initially prompted the patient to visit the clinic. Technical language should be used only sparingly, if at all, and words should be chosen to address directly the patient's initial concerns. For example, the clinician might say, "You don't have a brain tumor" instead of saying, "There is only a 2% chance that the MRI result would be positive." Other important tasks are to involve the patient in making the final decision about treatment and to check for adherence to prescribed therapeutic regimens.

Conclusion

The Four Habits Model1 serves as a useful communication template for enabling clinicians to say no to patients who demand inappropriate drugs or medical procedures. Clinician-patient conflict--and the nonadherence that frequently results from this conflict--can often be avoided if the clinician uses empathetic, clear communication; negotiation based on acknowledgment; the ability to set boundaries; and flexibility.

References

  1. Frankel RM, Stein T. Getting the most out of the clinical encounter: the Four Habits Model. Perm J 1999 Fall;3(3):79-88.
  2. White MK, Keller VF. Difficult clinician-patient relationships. Journal of Clinical Outcomes Management 1998 Sep-Oct;5(5):32-36.

 

 

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