Saying No to Patients Means Listening First

I recently saw this article in American Medical News about patient satisfaction and how sometimes it can lead to concerns when physicians who believe they are making the most well-considered treatment decisions encounter disagreement from patients about those decisions; see link Patient satisfaction: When a doctor’s judgment risks a poor rating – amednews.com . This could lead to poor patient satisfaction ratings and in some cases could lead to not receiving financial rewards based on those ratings. It can occasionally come down to saying “no” to patients who might be requesting procedures and medications that could cause them more harm than good.

Many doctors have difficulty saying “no” to some patients, although according to a 2012 study published in the Archives of Internal Medicine, when we say “yes” in effect, and patient satisfaction goes up, the higher patient satisfaction ratings tend to be associated with higher inpatient use, higher overall health care and prescription drug expenditures, and even higher mortality [1]. The conclusion of this study is that while patients may ask for services, not all of those services provide benefit and are actually deadly in some cases. Yet, doctors give in to patient requests, get higher satisfaction ratings, but risk poor outcomes.

The authors noted that their findings “suggest that patient satisfaction may be particularly strongly linked with prescription drug expenditures.” What was very interesting is that more satisfied patients were not necessarily subjectively sicker; in fact they more often rated their health as excellent. And the strength of the association between high patient satisfaction and increased mortality actually got stronger after excluding patients with poor self-rated health and substantial chronic disease burden.

The authors comment that we probably don’t fully understand what drives patient satisfaction and how they influence health care use and outcomes. They go on to say, “Therapeutic responsibilities often require physicians to address topics that may challenge or disturb patients, including substance abuse, psychiatric comorbidity, nonadherence, and the risks of requested but discretionary tests or treatments. Relaxing patient satisfaction incentives may encourage physicians to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients.”

This begs the question of what does “patient-centered care” mean? It probably doesn’t mean that we should give patients everything they ask for in a misguided effort to achieve high patient satisfaction ratings. That sounds obvious, but when the rubber hits the road, financial incentives may take priority over level-headed discourse with patients which starts by accepting that we have to sit down and spend time with them, discussing the rationale for our recommendations. Many times I have had to say “no” to patients and it most often has to do with safety. If I couch it in those terms, it sometimes makes the message easier for the patient to take. But that doesn’t work unless I listen to them first–and sometimes it just doesn’t work whether I listen or not. Most of the time, if I take the time, these difficult conversations  start with empathic listening for understanding. Many experts in communication believe that this is what doctors just naturally employ in all their visits with patients. Maybe we ought not just assume that.

1. Fenton Jj, J. A. F. B. K. D. F. P. (2012). “The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality.” Archives of Internal Medicine 172(5): 405-411.
Background  Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.Methods  We conducted a prospective cohort study of adult respondents (N = 51 946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36 428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.Results  Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).Conclusion  In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

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Comments

  1. Brilliantly stated!

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