San Francisco physician Dr. Rahul Parikh, writing in Salon recently, wondered out loud why some doctors have a hard time saying the word “NO!” to their patients. For example:
“I periodically get requests from parents to prescribe cough medicine for their child that contains codeine. Besides the codeine, the drug contains alcohol, naturally leading to a better night’s sleep for child and, hence, the exhausted parent.
“But there’s no evidence that this cough medicine helps the child get better any faster, and it may even be dangerous.
“Should I prescribe it or not? The evidence says no, but to say that can lead to a confrontation with an angry parent.”
He also cites the extensive related research on this topic undertaken by Dr. Richard Kravitz at the University of California at Davis. Dr. Kravitz’s research has shown that somewhere between 10-25% of patients bring a specific request to their doctor’s appointment. This request could be for a prescription drug, an x-ray, a scan or a medical procedure.
Patients who do not have their requests met:
- rate their physician lower
- are less likely to adhere to their doctor’s recommendations
- use more health care resources than those who do get their request met
Physicians who encounter a patient with a specific request also report these visits to be stressful and unsatisfying as well.
Why is it so hard for many doctors to say no?
Dr. Parikh writes that it’s often just easier for a physician to say yes to a patient.
“Usually, we’re behind schedule, with a waiting room full of impatient people, and we have a desk full of phone messages to return and charts to finish. To take even a few extra minutes and open the conversation — even a confrontation — about a request is time and energy we don’t want to expend.
“So we put pen to paper, rip the script off the pad and hand it to them as we rush out the door.”
Dr. Parikh adds that in pediatrics, where limiting the overuse of antibiotics is a priority, it’s recommended that doctors not prescribe drugs in most cases of middle-ear infections.
“Instead, since evidence suggests most ear infections get better on their own pretty quickly, we can treat a child’s pain with over-the-counter drugs like ibuprofen. But just in case things don’t get better, we often keep an antibiotic prescription ready for the child for the parent to fill. Doctors call it a “safety-net prescription,” but MBAs know it as a contingency — a common negotiating tactic to satisfy both parties during a negotiation.”
In Dr. Kravitz’s UC Davis study, he was able to categorize how doctors tend to respond to specific patient requests:
“The most successful method is for the doctor to exercise a little curiosity and delve deeper. It’s not surprising, for example, to find out that a patient who comes in with headaches wanting an MRI had a friend or relative who died of a brain tumour, or one with a cough who wants an antibiotic who knew someone hospitalized with pneumonia.
“If both patient and doctor can get to the root of the request, they can, in many cases, discuss it and figure out a third way.”
And as physician and blogger Dr. Kevin Pho observed last month:
“The art of negotiation is a business skill that physicians will have to master as we move towards an era of patient-centered care.”
Dr. Joseph Weiner, chief of consultation psychiatry at North Shore University Hospital in Manhasset, New York once told a CNN interviewer:
“There’s constant pressure to say yes to things even when it’s not in the patient’s best interest. It’s become an everyday dilemma.”
For example, he said doctors sometimes submit to demands for a drug advertised on television (the so-called Direct To Consumer pharmaceutical company ads – illegal in all but two countries on earth: the U.S. and New Zealand) – even when that drug is not the best choice.
See also:
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The Ethical Nag 
Medicine is taught as a “science” but practiced as an “art”. More than pure “research (dodgy or legit) science” is involved in managing patients and their expectations. Ultimately as a doctor my role is to advise. People are free to ignore that advice. Sometimes I will make a stand. Other times it is seriously not worth it BUT there are ways of planting a seed for next time. One of my favorites is “you can have a script for an antibiotic but it will do nothing for you.” Reverse placebo if you like.
As patients become consumers,they too need to take responsibility for decisions they make.
Not everything can be loaded onto the doctors shoulders.
I agree, Dr. Joe. That’s why it must be particularly frustrating for docs in countries (the U.S. and New Zealand) that still allow Direct To Consumer (“Ask Your Doctor”) pharmaceutical ads – whose sole purpose is to get the consumer to walk into their doctor’s office demanding the drugs featured in these DTC ads.
I did a quick jaunt through Google and it seems that NZ and the U.S. are the only two countries that allow DTC drug ads on TV. Is that the latest information? But that’s circumvented sometimes by cable transmission from the U.S. to Canada and Mexico. And other weasel ways.
Two sentences gleaned:
1. […] many doctors neglect to take the time to explain all the potential side effects of a drug. Likewise, many patients fail to thoroughly read all the literature the pharmacy provides with the prescription.
And how can they in the little time they have with patients a la HMOs? Plus the doctors would have to educate the patient about what a Western Blot is, for example. There goes more time.
2. […]there is a benefit to consumers in knowing about new medicines and their possible side effects.
We-e-e-lll, I dunno. It depends on where the consumers get that information? Would they learn medicaleze enough to read the ‘terror sheets’ (package inserts)? Or would they consider Oprah or Dr. Oz the ultimate in valid information?
I agree that it’s the consumer that has to stay on their toes—- it’s their responsibility. But, thereby hangs many tails, which I won’t mention right now.
Hi Cave – YES, the U.S. and N.Z. are the only two countries in which Direct To Consumer ads are legal. You’re right – I live just a 2-hour ferry ride from Seattle across the border, so we are exposed to lots of American TV ads here. But in 2000, for some nutty reason, Canada changed gears to allow ‘reminder ads’ for prescription drugs – thus becoming the only country on earth that prohibits DTC ads, yet makes an exception for branded reminder advertising. This is a form of advertising that states the brand name of the drug without any health care claims (like the famous dancing/jumping man Viagra ads you’ve probably seen on TV). Reminder ads are prohibited in all other developed countries that ban DTC ads. More on this at: “Top 10 Most Misleading Drug Ads“.
cheers,
C.