It can be a fine line for a physician to navigate, as many everyday ethical challenges may involve low-risk clinical decision making. The value of patient satisfaction scores and their impact on physician clinical decision making are currently under discussion in the medical ethics community, as concern rises regarding what ultimate effect they may have on patient care.
Explore this issue:December 2018
Maintaining the Physician–Patient Relationship
There are many reasons why physicians may find it hard to “say no” to a patient. Primarily, a physician has a sense of responsibility to the patient and values a positive patient–physician relationship. There are enough challenges these days to this relationship without mishandling a disagreement regarding patient requests versus physician judgment, especially if the request has a low risk:benefit ratio. In an established relationship, discussions about patient requests tend to be a bit easier than those occurring with a new patient.
“Demanding” patients encompass a range of severity; the easiest may require a simple explanatory discussion, while the hardest may pose significant risks to the patient and significant challenges to the physician. There are a number of generally accepted recommendations for physicians in dealing with patient demands: maintaining a calm and understanding demeanor, listening actively for underlying concerns, observing patient body language and facial expressions, delineating the boundaries of the physician’s clinical care, providing positive reassurance, and explaining what the physician feels is in the best interest of the patient. It is particularly important to investigate the “unstated” concerns that may be driving the patient’s demands and that may reflect underlying non-organic difficulties with which the patient is dealing. Human beings are complex, and the experienced physician will understand the potential impact of the psyche on wellness/illness and human behavior.
In addition to reasons listed above, physicians may find it difficult to “say no” to patient requests out of a sense of responsibility to help the patient, the desire to avoid a confrontation, and the question “what harm could it do?” The latter depends a great deal on just what it is the patient is requesting, and whether the requests are concerning or inappropriate for the physician’s particular practice or could clearly lead to additional requests of more serious concern. Even with acknowledgement of clinical practice guidelines, some requests are not “clear-cut,” and may fall along the “gray line” of propriety. Further discussion can be quite helpful.
In this particular scenario, the patient is requesting a medication that is clearly not indicated (antibiotic) based on the history and clinical examination. The otolaryngologist can explain to the patient that there is no evidence of an infection, and can review the neuroanatomy of cervical afferent nerves that may be compromised due to cervical spine disease secondary to trauma. A clear and concise explanation of the otolaryngologist’s premises, along with a recommendation for further imaging and consultant evaluation, using terminology understandable by the patient, will be quite helpful. All potential etiologies for otalgia should be considered, and further diagnostic testing predicated on likelihood of occurrence. The patient should be allowed to ask questions—just not for an inordinate amount of time—and be reassured that the otolaryngologist will work with her to identify the etiology and refer the patient to the appropriate provider if the cause is not within the scope of otolaryngology-head and neck surgery.