Tips to Help Clinicians Say No to Inappropriate Treatment Requests

A report in the February 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals says that clinicians may use one of several approaches to deny patient requests for an inappropriate treatment while preserving the physician-patient relationship.

Patients request medication during approximately one in ten office visits, and most requests are granted, according to background information in the article. "Medications prescribed at the behest of patients may not always represent physicians'' first choice of treatment, particularly if the requests are commercially motivated, as for example, by direct-to-consumer advertising," the authors write as background information in the article. "Nevertheless, physicians are cautious when rejecting patient requests for services, in part because of physicians'' perception that rejection may lower patient satisfaction."

Debora A. Paterniti, Ph.D., of the University of California, Davis, in Sacramento, and colleagues analyzed data from a randomized trial on the behavior of primary care clinicians in response to requests for antidepressant medication. Standardized patients who were trained to request antidepressants made 199 initial visits to primary care offices in Sacramento, San Francisco and Rochester, N.Y., in 2003 and 2004, complaining of "feeling tired" and also of either wrist or low back pain. Transcripts of audio-recorded visits in which requests were denied were analyzed and assessed for strategies used to communicate denial.

Of the 199 visits in which antidepressants were requested, clinicians did not prescribe them in 88 (44 percent), and 84 of those were included in the analysis. Clinicians used six primary approaches to deny the requests.

In 53 of 84 visits (63 percent), physicians used one of three strategies that emphasized the patient''s perspective. These approaches included exploring the context of the request by asking questions about where the patient heard about the drug and why they thought it would be helpful; recommending that the patient seek the advice of a counselor or mental health specialist; or offering an alternative diagnosis to major depression.

In 26 visits (31 percent), clinicians took biomedical approaches, either prescribing sleep aids instead of antidepressants or ordering a diagnostic workup to rule out conditions such as thyroid disease and anemia. In five visits (6 percent), clinicians simply denied the request outright.

"The standardized patients reported significantly higher visit satisfaction when the physician used a patient perspective-based strategy to deny their request for antidepressants," the authors write.

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"Elucidation of these strategies provides a more nuanced understanding of physician-patient communication and negotiation than has been described previously," the authors write. "These strategies provide physicians with alternatives for saying no to patient requests for care that is perceived to be inappropriate, offering physicians an opportunity to select approaches that fit their own style of communication, the preferences of particular patients or changing organizational climates."
(Arch Intern Med. 2010;170[4]:381-388. Available pre-embargo to the media at www.jamamedia.org.)

Editor''s Note: Co-authors Dr. Fancher, Dr. Paterniti and Dr. Kravitz were supported by National Institute of Mental Health grants. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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