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Handling Patient Demands

MAJ/P Elizabeth Duque, MD, MBAUSAFP 2015

Dilemma

1. Media, Celebrities, Internet2. Doctor – patient relationships3. Customer service focus4. Culture of society5. Limited time 6. Ethics

Conflicting ethical considerations

• Patient autonomy versus professional integrity

• Autonomy versus do no harm (risks and benefits)

• Cheating versus justice (stewardship)

Case Studies

1. A 28 year old female comes in requesting her “annual blood work”.

2. A patient comes in demanding a referral to neurology for headaches. She has never been evaluated or treated for them before.

3. A patient comes in requesting Vicodin for back pain? What if it were Celebrex?

Some data• 24% of physicians view patient requests as positive• 43% view them as having a negative impact on patient care and

interactions

• More than 10% of patients will make a request for a specific medication

• 19.8% of patients will receive a narcotic if they request on• 1% will receive a narcotic if not requested• 53% will receive Celebrex if requested• 24% will receive Celebrex if not requested

• 85% of ER providers ordered CXR if requested, even thought 0% thought it was clinically indicated

How do you respond?

YESNO

Maybe

Before Responding

SELF AWARENESS

• Understand your own biases

• Challenge your initial assumptions

Before Responding

Understand the Patient’s Request

• What is the context of the request• What is the authenticity of the requests• What is the underlying concern• What assumptions/biases does the patient bring

Before Responding

Know Your Bottom Line• Set boundaries

• For what will you fall on your sword for?

• Patients cannot insist on treatment that is against your clinical judgment

Before Responding

Consider Alternatives• This is where prep work becomes important?

• Can you seek a consensus with the patient?

• Are there research opportunities or other sources for the patient to be involved in that would meet the patients needs?

Case Studies

1. A 28 year old female comes in requesting her “annual blood work”.

2. A patient comes in demanding a referral to neurology for headaches. She has never been evaluated or treated for them before.

3. A patient comes in requesting Vicodin for back pain? What if it were Celebrex?

Responding

YESNO

Maybe

Summary

• Patient demands are common and can challenge providers• There is no set way in which to respond• Appeal to authorities (organizations, guidelines,

etc…)• Listen and work with patient • Continue to emphasize with patient• Maybe is often the best answer but hardest to

get to.

QUESTIONS?

References• Asscher, E., Bolt, I., & Schermer, M. (2012, June). Wish-fulfilling Medicine in Practice: a Qualitative Study of Physician

Arguments. Journal of Medical Ethics, 38(6), 327-331.• Ballard, D., Reed, M., Wang, H., Arroyo, L., Benedetti, N., & Hsu, J. (2008, December). Influence of Patient Costs and

Requests on Emergency Physician Decisionmaking. Annals of Emergency Medicine, 52(6), 643-650.• Brett, A. S., & McCullough, L. B. (2012, January 11). Addressing Requests by Patients for Nonbeneficial interventions.

Journal of American Medical Association (JAMA), 307(2), 149-150.• Burger, I. M., & Kass, N. E. (2009, April). Screening in the Dark: Ethical Considerations of Providing Screening Tests to

Individuals When Evidence is Insufficient to Support Screening Populations. The American Journal of Bioethics, 9(4), 3-14.• Ferrante, J., Shaw, E., & Scott, J. (2011, October). Factors influencing Men's Decisions Regarding Prostate Cancer

Screening: A Qualitative Study. Journal of Community Health, 36(5), 839-844.• Gregory, S. (2005, May 19). Preparing for Practice: Difficult Patient Requests. Update, 70(5), 80-84.• Henry, L. A. (1998, September). Demand Management: The Patient Education Connection. Family Practice Management,

5(8), 65-70.• Lorenzetti, R. C., Jacques, C. M., Donovan, C., Cottrell, S., & Buck, J. (2013, March 15). Managing Difficult Encounters"

Understanding Physician, Patient and Situational Factors. American Family Physician, 87(6), 419-425.• Maizes, V. (2000, February 1). Setting Limits on Demanding Patients. American Family Physician, 61(3), 881-882.• Malm, H. (2009, April). On Patient Requests for Unproven Screening: Dim Guidance for Screening in the Dark. The

American Journal of Bioethics, 9(4), 15-27.• McKinlay, J. B., Trachtenberg, F., Marceau, L. D., Katz, J. N., & Fischer, M. A. (2014, April). Effects of patient Medication

Requests on Physicians Prescribing Behavior: Results of a Factorial Experiment. Medical Care, 52(4), 294-299.• Paterniti, D. A., Fancher, T. L., Cipri, C. S., Timmermans, S., Heritage, J., & Kravitz, R. (2010, Feb 22). Getting to "No".

Archives of Internal Medicine, 170(4), 381-388.• Silberstein, N. (2010, January). Understanding and Managing Patient Expectations. Podiatry Management, 109-112.• Toiviainen, H., Vuorenkoski, L., & Hemminki, E. (2005, March). Physicians' Opinions on Patients' Requests for Specific

Treatments and Examinations. Health Expectations, 8(1), 43-53.