Saying No

Saying NoVICTORIA MAIZES, MD, Tucson, Arizona

Saying no to patients is not something that most physicians learn in medical school. Nor does it come naturally or instinctively. Rather, after years of trial and error, as patients ask for things that physicians consider inappropriate, physicians eventually develop a style that works for them.

How patients feel about their physicians’ saying no is another matter. No one likes to be told no. When physicians say no, patients often don’t return. They perceive themselves in a “one-down” situation. They may feel embarrassed and look for another physician.
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The specific situations are familiar ones. Whether the patient is asking for a third or fourth refill of Vicodin (combination product of hydrocodone bitartrate and acetaminophen) for chronic back pain, wants to be classified “disabled” for a problem that seems minor, or is convinced that magnetic resonance imaging is the only thing that will answer his or her questions, physicians have often heard these requests before. The automatic response often is to lecture the patient on why the request is not a good idea.

Yet, even as physicians say no, they struggle with it. There is often uncertainty in medical situations. One way to handle uncertainty is to trust the patients. Physicians want to be liked. Finally, saying no takes longer (at least initially) than “giving in” and granting patients their requests. But if physicians give in, they then feel compromised.

When searching the literature to prepare this article, I was surprised to find that nothing had been written on the topic. I questioned colleagues, who concurred. Yet, interest among practicing physicians is high. Managed care’s quarterly member-satisfaction surveys give physicians an incentive to improve their communication skills. A “No” said without finesse often leads to a patient complaint, another item tracked by many health maintenance organizations.
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As a brief negotiation trainer (Brief negotiation is a communication skill that clinicians use to increase patient motivation to make lifestyle changes.), I repeatedly heard the question, “What about when you have to say no?” In a series of focus groups, I developed and tested the following seven steps and found them effective in preserving the physician-patient relationship.

Step 1. Listen
Make sure you clearly understand what the patient is asking for. A patient’s request for a magnetic resonance imaging scan may be a request for a more specific diagnosis.

Draw the patient out with encouraging comments like “Tell me more.” This is counterintuitive because the physician’s initial impulse usually is to try to stop the patient from talking.

Step 2. Acknowledge
Restate your patient’s request so he or she knows you’ve heard and understood the request.

Use reflective listening. For example, in response to a patient’s request for diet pills, reflect back: “What I hear you saying is, you really want to lose weight,” or, in response to a request for pain medication: “You really want to reduce your pain.” It is important not to trivialize the patient’s experience.

Step 3. Preamble
Develop your own introduction. For example: “I know this is something you were really hoping I could help you with,” or “This is really difficult for me to say.”
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Step 4. Express Empathy
Empathy toward the patient needs to be genuine. Consider how you felt when an authority figure refused one of your requests.

Find your own language. For example: “I care about you; I would like to work with you to try to find a solution.”

Step 5. Explain Rationale
Your patient may or may not be willing to hear your rationale (due to anger, frustration, and so forth). Summarize your reason briefly, using terms that are clear, plain English, not medical jargon.

Ask permission before giving a longer explanation. “Do you want to know more?”
Use “I” language. For example: “I don’t prescribe Vicodin for chronic pain because I find… ,” not “You shouldn’t use Vicodin because you may become addicted.”

Step 6. Ask for a Response
Requesting a response from the patient helps assess whether the patient has understood your perspective. “Do you understand why I can’t . . ?” Listen to the answer.

Step 7. Assess Readiness to Consider Other Options
Ask the patient, “Would you be interested in exploring other options?” If the patient is not ready, don’t push other options.

These seven steps help protect the therapeutic relationship with patients when physicians must say no. They need not be followed sequentially, and the spirit in which they are communicated is undoubtedly more important than the actual words. Although they cannot ensure that every patient visit ends on a positive note, they are likely to help.

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