Perspective: The fine art of saying ‘no’

24 May 2010

By Jim Killgore, editor MDDUS Summons

Are we living in a culture of ‘yes’?

US emergency physician and blogger Dr Edwin Leap thinks so. He writes on the medical blogging website KevinMD.com:

“We live in a culture of spoiled children of all ages who think that the only answer to any question is a resounding “yes.” Yes to admissions for convenience. Yes to endless care at no cost. Yes to validating non-diseases. The ridiculous parenting attitudes of the past 30 to 40 years translated into a society of adults who throw tantrums when they don’t get what they want, medically, personally, economically, or politically.

"And once they grow out of stomping their feet and holding their breath, they move on, and fill out angry satisfaction surveys or write scathing evaluations of their doctors or anyone who denies them, in anonymous online forums.”

His is a view not all UK health professionals might necessarily sign up to but it certainly would touch a nerve in most.

Recently the BMA made public its response to the Care Quality Commission (CQC) consultation on assessment of quality in health and social care. In a statement the BMA warned that future monitoring of the NHS and doctors should not be too focused on patient surveys as these might reflect a doctor’s popularity rather than his or her quality of care.

It said: “There is the danger that the patient experience may be confused with quality of care and that doctors are rated for their popularity rather than the quality of their service. That is not to say that the patient experience is necessarily less important than clinical quality, particularly where the condition is less serious, rather that both need to be seen as separate entities worthy of assessment.”

Despite this worry the BMA generally supports the CQC’s proposed aims for quality assessments. But their response highlights the risks of using patient feedback in judging what constitutes good healthcare – a danger that doctors or dentists may be judged simply on the basis of patient expectation to “have it your way” (as Burger King promises).

Keeping patients onboard but...
Doctors and dentist face it everyday – unwarranted requests for antibiotics or painkillers, doctor’s lines, heroic treatments to save rotten teeth or a desire for a smile like Simon Cowell on TV. Certainly all healthcare professionals have an ethical obligation to listen to their patients. GMC guidance on consent advises respect for patient views but if a doctor judges that a particular treatment “would not be of overall benefit to the patient, they do not have to provide the treatment”. It adds: “they should explain their reasons to the patient, and explain any other options that are available, including the option to seek a second opinion.”

MDDUS medical adviser Dr Barry Parker says: “The key thing in avoiding a patient complaint if you are having to say ‘no’ is to give as clear an explanation as possible why the treatment is not in the patient’s best interest.”

Dentists face similar dilemmas and in some cases are subject to even greater patient pressure. MDDUS dental adviser Claire Renton says: “You need the cooperation of your patient; you must have them onboard as there is no point in trying to impose treatment. But there is a fine line here – you must not allow yourself to be persuaded to do treatment that you think is not necessary or wrong.”

“It’s particularly an issue for patients coming to dentists for cosmetic treatment where the promise of high treatment fees can add to the temptation of saying ‘yes’ to patients who may have unrealistic expectations of both what’s available and what’s appropriate for them.”

An effective 'no'
So what is the best approach when clinical judgment dictates saying ‘no’ to patients?

Researchers at University of California recently looked at 199 visits to primary care doctors in which patients requested an antidepressant – the kind of request that doctors in the US are perhaps more familiar with because of direct advertising to consumers. In 84 visits the request was denied and the researchers examined various approaches among the clinicians in saying 'no'.

Six per cent offered a flat 'no' while 31 per cent took a “biomedical approach” – either prescribing sleep aids instead of antidepressants or ordering a diagnostic workup to rule out conditions such as thyroid disease and anaemia. In 63 per cent the doctors emphasised the patient's perspective, exploring the context of the request by asking questions such as where the patient heard about the drug and why they thought it would be helpful, recommending the advice of a counsellor or mental health specialist or offering an alternative diagnosis to major depression. It was this approach that elicited highest patient satisfaction.

Charles E. Schwartz, an associate professor of psychiatry, family medicine and medicine at Albert Einstein College of Medicine and expert in communication skills comments: "What we find in dealing with patients is that even if you disagree, you have to start where the other individual is starting. If you meet them where they are, you might be able to lead them somewhere else."

No doubt there are many ways in which patient feedback (positive and negative) can be taken into account in improving the quality of care and service provided by the healthcare profession – and to improve health outcomes.

But being a successful doctor or dentist is not a popularity contest; nor can medical care be treated solely as a commodity subject only to market forces – to do so would be a true disservice to patients.