Just Say “No”

Maybe they plead for stronger medications. Maybe they tie up your phones with minor complaints. Maybe they lobby for tests that they don’t really need. Every medical practice has its share of challenging patients. To treat them effectively, providers must learn where to draw the line and how to deny patient requests without damaging trust.

However, in the era of patient-centered medicine, however, in which patients are encouraged to participate in health care decision-making, just saying “no” is not enough. There must be empathy and education, as well. The American Academy of Family Physicians (AAFP) suggests that doctors in these situations first offer the balm of regret. Indicate how sorry you are that you don’t have time to answer their calls personally, or let them know that you understand how much they wanted a particular prescription and that you’re sorry to disappoint them.

Then explain the reason for your refusal. Perhaps the prescription is highly addictive, which can create bigger problems later. Maybe the medication becomes less effective the longer it is used. In cases like this, it might help to explain to the patient that if something really bad happened to them, like a car accident, you wouldn’t be able to alleviate their pain at all.

Greater access to information via medical Web sites, the media, and marketing firms has also empowered patients to push for tests and procedures that may not be appropriate for their symptom set. In such cases, reason works best. Explain that the test is not designed to diagnose their condition, and, as such, constitutes an unnecessary expense. Tell them, too, that the Web is full of misinformation and that blind probing (as with full body scans, which were popular several years ago) can cause undue emotional stress. During the course of your discussion, it’s important to take responsibility for your decisions as well, says the AAFP. If you tell your patient simply that you can’t prescribe a medication, he’s likely to reappear with multiple petitions, anticipating the day when you give in. Instead, tell him that you have your own professional standards and won’t prescribe anything that could cause harm.

Finally, explain what you’re willing to do for your patients and what you expect them to do for themselves. For example, you might provide only a 1-month prescription and require a follow-up visit to discuss their condition thereafter. Perhaps physical therapy, exercise, or a change in diet would help alleviate their symptoms.

Above all, be firm, says the AAFP. Don’t prolong your explanation or talk in circles, and never argue. By restating your reasons in plain language, the patient will quickly learn that arguing won’t change your mind. It may help, too, the AAFP adds, to put your response in writing—especially for the extremely persistent patient. Indeed, written documents reinforce your message and can be useful for patients who have difficulty processing information during encounters because of anxiety.

The trend toward patient participation in health care is widely viewed as a positive step, but that doesn't mean patients call all the shots. Indeed, a key factor in the practice of medicine is steering patients toward the remedies they need, not necessarily the ones they request. And sometimes, that takes saying “no.”