How denying patient requests may not impact patient satisfaction

Does physician denial of patient requests result in decreased patient satisfaction?

The short answer: No.

At least not in the context of a strong physician-patient relationship.

Many physicians have legitimate concerns about the prospects of having their salary or level reimbursement linked to patient satisfaction. I would too given the way most health care providers go about measuring and interpreting patient satisfaction data.

A major concern of physicians is the issue of patient requests – particularly the impact of unfulfilled (and unreasonable) requests upon patient satisfaction. According to researchers, explicit patient requests for medications, diagnostic tests and specialty referrals occur in between 25% to 40% of primary care visits. This figure is much higher when requests for information are factored in.

In studies, primary care physicians accommodate patient requests for medications and diagnostic tests approximately 75% of the time. Physicians however accommodated only 40% of specialist referral requests. Physicians negotiated alternatives solutions to patient requests 22% of the time and denied patient requests the remaining 3% of the time. Information requests were met approximately 95% of the time by physicians.

Denial Of patient requests has little impact on patient satisfaction

It is not at all clear from the research that physician denial of patient requests for medications, tests or specialist referrals has any negative effect on patient satisfaction. In the studies referenced here, little to no association was found between unfulfilled patient requests and patient satisfaction.

The one exception to this finding is where physicians fail to meet patient requests for health information. In such instances patient satisfaction was lower. This is not surprising when one study categorized the quality of physician responses to patient information requests as follows:

  • 32% were of requests were fulfilled with a “terse” physician response
  • 33% percent were fulfilled with an “intermediate” response
  • 32% percent with an “elaborate” response.

Experts advise negotiating patient requests

It has been said that clinical encounters such as occur during office visits involve a “process of negotiation between the clinician and patient.” As such, physicians are advised to use the influence accorded them by their patients to help them understand the pros and cons of their request so as to negotiate actions are really needed.

Physicians that are truly concerned about their patient satisfaction score are better served by looking after the quality of their patient communications skills.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • http://med-path.blogspot.com/ thunderroad

    This makes a lot of sense. Patients rightfully see their doctors as medical experts, and as such it is reasonable to accept that physicians will not accommodate treatment and referral requests they don’t believe are warranted. When asking for information however, failure to follow through can give the impression that their doctor isn’t invested in how comfortable patients are with their care.

    I went to see my PCP for cold symptoms that had persisted for more than a week. She promptly prescribed me an antibiotic. I asked her how she knew that the infection was bacterial and not viral without doing a culture. She looked a bit surprised. I think that most patients don’t care, they just want the antibiotics. She explained that viral infections tend to resolve faster. I really only wanted her to have an answer. I wasn’t looking to second guess her. I am not the kind of patient that wants antibiotics for no reason. I want my doctors to make decisions based on science and not my whims. Diagnosis and treatment are areas where doctors should behave like scientists. It’s in in the dialogue where empathy and humanity come in to play.

    • Lil A

      I agree, there is both an art and a science to medicine. It’s a constant balancing act between giving appropriate care and being sympathetic to the patient while giving this care.

      I have had experiences where refusing to provide me with what I wanted was in my best interest. There are times when giving what the patient wants would harm them, and it is up to the physician to explain this to the patient. However, it is also up to the patient to ask questions about their care as well. Good care is up to both the physician to offer and up to the patient to seek.

      I also agree that it can be up to negotiation between the physician and the patient. Physicians should be willing and able to provide the pros and cons to tests and procedures, and patients should ask if the tests are really necessary.

  • https://www.dialdoctors.com/ DialDoctors

    I completely agree with @thunderroad. Patients look up to physicians as a source of health information expertise and they have expectations and are eager to be fulfilled by their knowledge. It is reasonable to agree that physicians will not accommodate treatment and referral requests that some patients demand and they don’t believe are justified.

    However, as Steve mentioned ,the one exception to this finding is where physicians fail to meet patient requests for health information. This does back-up the patient feeling unsatisfied towards physician care. Doctors should have the ability to manage questions, look into EACH patients’ particular case and provide a treatment suitable for them specifically.

  • Tex D0c

    Fine, folks – IF:
    1. Patients agree not to doctor shop at their whim, but actually try to have a medical home,
    2. ED’s are allowed – perhaps required – to triage out the “7-11″ shopper and send them back to a PCP for their “it’s Saturday night and I’m bored and stuffy-nosed” URI visit – without the Patient Satisfaction Survey threat being held over them, and
    3. How much time, DD, do you allot for “Doctors should have the ability to manage questions, look into EACH patients’ particular case and provide a treatment suitable for them specifically.”…and how much are you willing to pay for same?

    The lack of concordance between patient and insurer’s expectations, clinical reality, and financial reality is truly enormous.

    • Lil A

      “The lack of concordance between patient and insurer’s expectations, clinical reality, and financial reality is truly enormous.”

      This is so true. It’s in the patient’s best interest to spend proper time with their patients, but insurance companies do not want this. They believe that the less one spends with their doctor, the better off they are, when this is not the case. When patients try to have a relationship with their doctor, their quality of care improves. However, because physicians are pressured to meet quotas and satisfy insurance companies, this never usually becomes a reality. On top of it, patients want to keep their costs down, which means that they get to see more of nurses but not the doctor. While this can keep costs lower and is even better in some cases (why see the doctor to remove a splinter when a nurse is perfectly able to remove it with the same quality of care), it can be hurtful in other cases, especially when the eye of an experienced specialist is needed.

      “Patients agree not to doctor shop at their whim, but actually try to have a medical home.”

      I, as a patient, have tried this before, and I go to different doctors until I find the one that suits me. However, also take into account that people move and cannot continue seeing the same doctor without costing them good money. Sometimes people doctor shop to find the right one for them, and this shouldn’t be held against them. I even support going to another doctor to get a second opinion. It never hurts to have a second person on the case, and two heads can be better than one. However, if patients are going to different doctors to supply an addiction, that is where I think that the patient is in the wrong. I don’t know if this is true or not, but I now am hearing of a database where doctors can go on to see what person is getting what narcotic prescription from which doctor. If this is truly available, then great, if not, then I advise getting something like this. As soon as it is realized that this person is going around getting narcotic prescriptions from multiple doctors at the same time, then the doctor can decide whether or not he wants to write yet another prescription for it. It would hold the patient responsible and would place less risk on the doctor for prescribing it.

      “ED’s are allowed – perhaps required – to triage out the “7-11″ shopper and send them back to a PCP for their “it’s Saturday night and I’m bored and stuffy-nosed” URI visit – without the Patient Satisfaction Survey threat being held over them…”

      I agree with this one as well. I have been to the emergency room where someone was waiting four hours and was in their for the upteenth time that day with a sick child. She was told by several ER docs that her child had a virus and to go home, yet she insisted on getting something prescribed. In the end, they didn’t even triage her or her child, because it was such a pain. She spent several hours in the waiting room and finally left, angry that they would not prescribe something for a cold. These types of cases should NOT be held over the head of the physician, as they are doing what they can and what is in the best interest of the patient. Prescribing antibiotics in a case like this will only serve to form superbugs, or to get the patient’s hopes up, just so that you can see them back a couple days later, claiming that the antibiotics didn’t work and possibly ending up in a lower patient satisfaction score. Either way, it’s lose-lose. You try to make them happy, you’re risking the health of everyone else. You preserve the health of everyone else, and you end up with a low patient satisfaction rating and people getting after you for this. The decision, at this point, has to be made based on how many will benefit from your decision and not based off how happy you can make one person. After all, it is impossible to make everyone happy at every moment of the day.

  • Kristin

    This isn’t clear to me:

    “According to researchers, explicit patient requests for medications, diagnostic tests and specialty referrals occur in between 25% to 40% of primary care visits. This figure is much higher when requests for information are factored in.”

    I don’t find it in any way worrisome that “this figure is much higher when requests for information are factored in,” but the phrasing suggests that perhaps I should. Why wouldn’t a patient want some information about what’s wrong with them or what they can do about it? What else does a patient go to a doctor for? Do people really just show up and go, “I’m broke, just fix me, don’t tell me anything about it”?

    Are we really trying to make “asking for information” a burden on the same order as “I want an MRI and I want to see a cardiologist about this thing that you say is heartburn”? Because one of those things is rational, and one of them is not.

    “Information requests were met approximately 95% of the time by physicians.”

    Well, it can’t be too burdensome, at any rate.

    • http://nomidazola.blogspot.com Jackie

      Kristen, thanks for seeing this! I noticed right off the bat that patient requests for information were being treated as an unreasonable expectation. Only 95% of the time requests for information were “met.” Wow. This is exactly my beef with medicine today. I am not a sub human entity who wishes to be treated the same way my vet treats my critters. I want to know all about what the problem is, the ways it can be addressed, and a FULL disclosure about the risks and benefits of what the Dr. wants to do. Seems to me that there are laws about this very thing??!! I would also like my physician to have at least some inkling of how much these tests/treatments cost before he/she tries to foist them off on me. I admit that I am at the opposite end of the spectrum from the patients apparently discussed in this article, the exception being my horrid waste of the Dr.’s time by wanting information.

      • Lil A

        You have the right to request information. If you had an attorney, you would want to spend adequate time so the case is handled correctly, right? The same goes for a physician. You have the right to request or refuse tests or to have the doctor explain to you how it will help and possibly hurt you so that what you have is treated right.

        And I agree that sometimes patients are treated like sub-human entities. That is why, if I feel like I am being treated this way, I find a different doctor to go to. It is within my right to find a doctor who I feel cares for me as a person and not more about the money I could possibly bring in to him. The best doctors that I have had spent time with me, explaining my condition (recently had an orthopedic surgeon I went to go through and explain the findings of the exam and x-rays-I had indicated that I wanted an explanation on my medical history form though too) and showing empathy toward me. I am more honest and hide less from these kinds of physicians than from the ones where I feel if I reveal too much, I will be beat over the head and made to feel like the “bad patient” and possibly even a bad person.

  • http://www.epmonthly.com/whitecoat WhiteCoat

    I find it ironic when those who have little or no experience in physician-patient encounters posit theories about how to improve the experiences of those encounters.
    Based on my 15 or so years of patient encounters and based on my 9 years of experience in addressing patient complaints after the physician patient encounters have taken place, I have found that there is a significant disconnect between what is reported on surveys and what truly happens in the examining room.
    I think that if you asked most practicing physicians (those who have no vested interest in the multibillion dollar patient satisfaction industry) the same question, you’d find the same answers.

    “It is not at all clear from the research that physician denial of patient requests for medications, tests or specialist referrals has any negative effect on patient satisfaction.”
    Steve, did you read the studies you cited?
    From the study in your “patient requests” link above:
    “Patients whose physician failed to fulfill 1 or more action requests (n = 41) registered significantly less visit satisfaction (mean satisfaction scale score = 4.06, consistent with an overall rating of “very good”) than patients whose every action request was fulfilled (n = 261, mean satisfaction score = 4.37) and patients who made no action requests (n = 257, mean satisfaction score = 4.38).”
    These statistics bear out what I’ve seen in practice – both clinically and administratively. Sometimes there are bad docs who get a lot of complaints. Many times, good docs get complaints from patients who don’t get what they want. Rather than saying that the “doctor wouldn’t give me inappropriate antibiotics for my nasal congestion” or that “the doctor wouldn’t refill my Vicodin prescription that I accidentally dumped in the toilet,” the complaints say that the doctor was “rude.” I don’t think that you’ll find a study with information like that, though. Therefore, based on a lack of studies documenting such occurrences, they must not occur, correct?

    You note another study showing that patient satisfaction is improved when physician responses are “elaborate” as opposed to “terse.”
    Your bio says that you used to be a hospital executive. You therefore know that administrators in hospitals have a lot of control over giving physicians more time to explain things to patients. If administrators hired more physicians to treat patients, the physicians would have more time with patients and then the problem would be solved, right?
    Is it fair for me to assert that lower patient satisfaction scores are really a measure of poor hospital administrator skills?

    The knife cuts both ways.

    • Lil A

      Very good points you bring up. I do agree that Steve has some power to increasing the time that a doctor spends with his patients.

      I have a question. What about those people that have been in the position of patient in many instances with many different doctors, both good and bad? Do those people bring something valuable to the table as well? I know that I often talk out of my own personal experience when I talk about how to improve the encounters with physicians. Granted, I’ve never been on the other end of things yet, but I will get a taste of some of it a few years from now when I have my BSN and RN licensure. However, I have a sense of it through conversing with those that work as healthcare workers and know full well how difficult it can sometimes be.

      I think that it’s important for patients to be sympathetic and listen to what physicians have to say and try to accomodate to what they say would make their lives a little easier. The physician should do the same as well. It should be an exchange, not a relationship where one lords what he knows (or what he thinks he knows) over the other. Both patients and doctors can do this sometimes, and it sets things up to end badly.

      • http://www.epmonthly.com/whitecoat WhiteCoat

        You sound like a very reasonable patient – one whom I would enjoy working with to help resolve any medical problems you had.

        However, the low response rate and other confounding factors in patient satisfaction scoring highly skew the results toward unreasonable patients. One unreasonable patient who is unhappy about not receiving a desired but medically inappropriate treatment can significantly decrease a physician’s satisfaction scores.
        Administrators don’t seem to care about the statistical shortcomings, only about the numbers generated.

        When satisfaction scores supplant medical judgment, the practice of medicine has a terminal diagnosis.

        • Lil A

          Thanks for the compliment. Too bad I live all the way in sunny Colorado. Classes got out for me a few weeks ago and I’m looking for a job and good GP in the Denver area.

          “When satisfaction scores supplant medical judgment, the practice of medicine has a terminal diagnosis.”

          This is so very true, especially when the scores are based on the unreasonable, unhappy minority instead of the happy majority.

          I think that basing a doctor’s pay off of patient satisfaction surveys is wrong. There are really good physicians out there who are looking out for the patient’s best interest in not prescribing medications, especially if the person is looking to sell the pills on the street or is looking to fuel an addiction. Just because a physician has a bad score doesn’t make them a bad physician, and just because they have a good score doesn’t make them the best either. High scores on patient satisfaction surveys does not equal performance. I can tell you that a physician who refuses to prescribe narcotics in an area where there are a lot of patients that have a narcotic addiction would be rated lower than one that handed narcotic prescriptions out like candy. Does that mean that the one that hands out narcotic prescriptions like candy is doing a service to their patients?