by Carolyn Thomas ♥ @HeartSisters
San Francisco physician Dr. Rahul Parikh wondered in a Salon column why some doctors have such 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.”
Dr. Richard Kravitz at the University of California at Davis has done extensive related research on this topic.(1) His studies have shown that up to 25% of patients bring a specific request to their doctor’s appointment. This request could be for a prescription drug, a diagnostic test, 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 requests 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 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 research, 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 because he 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 once observed:
“The art of negotiation is a business skill that physicians will have to master as we move towards an era of patient-centered care.”
As Dr. Joseph Weiner at North Shore University Hospital in Manhasset, New York 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 – advertising that is illegal in all but two countries on earth: the U.S. and New Zealand) – even when that drug is not the best choice for the patient.
Drug companies are not spending $3 billion per year running expensive Direct To Consumer drug advertising campaigns out of the goodness of their hearts. These ads do work to sell more drugs (perhaps why almost all other countries on earth ban the practice, and also why last November, the American Medical Association voted for a ban on all direct-to-consumer advertising for drugs and medical devices).
A study published in the American Public Health Association journal, Medical Care, for example, found that two groups of patients who made a specific request to physicians for the narcotic drug oxycodone for their sciatica pain or for the painkiller celebrex for their knee osteoarthritis were significantly more likely to get the particular drug they asked for compared to two groups of patients who simply asked for “something to help with pain.”(2)
What can you do to help stop all of this?
The Choosing Wisely campaign aims to promote conversations between health care providers and patients by helping us choose care that:
- is supported by evidence
- doesn’t duplicate other tests or procedures we’ve already received
- is free from harm
- is truly necessary
To help us engage our health care providers in these conversations about what tests and/or procedures are right for us, Consumer Reports has developed patient-friendly materials based on specialty societies’ lists of recommendations. For common sense answers to health questions ranging from genetic testing to dietary supplements to prevent heart disease (spoiler alert: they don’t work), check out their resources here.
And check out this list of five Choosing Wisely recommendations from the American College of Cardiology on what commonplace cardiac tests or procedures are recommended – or not.
♥
(1) Richard L. Kravitz and Jodi Halpern. Direct-to-Consumer Drug Ads, Patient Autonomy, and the Responsible Exercise of Power. AMA Journal of Ethics. Virtual Mentor. June 2006, Volume 8, Number 6: 407-411.
(2) John McKinlay, Felicia Trachtenberg, Lisa Marceau, et al. Effects of Patient Medication Requests on Physician Prescribing Behavior: Results of A Factorial Experiment. Medical Care. April 2014 – Volume 52 – Issue 4 – p 294–299
NOTE FROM CAROLYN: A version of this post was originally published on The Ethical Nag: Marketing Ethics for the Easily Swayed in December of 2011. Because I’m working on a new book (A Woman’s Guide to Living With Heart Disease, Johns Hopkins University Press, November 2017), I find myself temporarily with fewer hours in the day when I’m able to write new blog articles here on Heart Sisters. I’m hoping that running some updated favourites from the archives of hundreds of Heart Sisters and Nag posts will keep you informed, entertained and involved each Sunday for a while. And although I’m not able to write as many new posts for the time being, I do love reading your comments – so please feel free to leave your response below. Meanwhile, thank you so much for your amazing support!
Q: Have you ever tried to talk your physician into a treatment, drug or test? Why or why not?
See also:
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Heart Sisters 
Doctors often complain of being over-worked. Yet, that is their choice. Patients should not suffer because the doctor is unwilling or unable to figure out how to solve their own problem. A cough does not require an MD or DO for a solution — where are the ARNPs and the PAs? There are lots of medical protocols for dealing with coughs and numerous other minor issues in medical care.
Patients should look for offices that have physician assistants as part of the team — simple problems often get better care.
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Good points, Dr. Beckett! I wish more docs were open to working alongside both physician assistants and nurse practitioners. These are not substitutions for physicians, but their roles can complement one another to improve patient care, allowing physicians to focus on more complex diagnosis and treatment.
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I’ve asked my doctor about tests, etc that weren’t really necessary, and have been pretty good at figuring out what’s wrong. But my special question is: what is a patient like me supposed to do when you know a medication has worked beautifully but your insurance company refuses to pay for it? I would love to see an article about that subject. Thanks.
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Hi Alise – if you’re in the U.S., there are some ways to appeal an insurance company’s refusal to cover your meds, e.g. to get your drug covered through the ‘exceptions’ process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition. If the exceptions answer is no, here’s a link to the appeals process. Good luck to you…
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It does seem very often to come down to time constraints, doesn’t it? Docs have limited time to see each patient, and may not ask that next question or two that gets at the real nature of a patient’s concerns.
I see this a lot at my end when people are struggling with pain management & aren’t allowed to take NSAIDs, or feel tired all the time, or are suffering from untreated anxiety or depression that often causes someone to focus on a whole list of other symptoms that are magnified by their anxiety/depression.
There has been movement afoot here in the U.S. to stop pharma from advertising drugs on TV. Those TV ads have become a joke, all of them ending with a rapid, incomprehensible list of potential side effects that most folks ignore. Oy. And then there’s the fine line between patients justifiably advocating for themselves and looking for easy fixes that don’t work. A condundrum.
Good post!
Kathi
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I think you’re right, Kathi – docs who are trying to stay on time must feel like throwing up their hands in despair when patients (educated by those DTC ads on TV) come in insisting on a very specific option. There’s also a bias for action, any action, even one that is NOT appropriate e.g. expecting to walk out with a prescription for antibiotics for a common cold.
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