A solution for patients who request unnecessary care

As an advocate of patient-centered care, I have to recognize that some varieties of patient-centrism make me more comfortable than others. If I really want the patient to do X, and the patient doesn’t want to, I generally feel okay about that. Frustrated, sure, and often times convinced that my way is the right way and the patient’s way is some sort of detour.

Most often, though, I am able to put aside those feelings and encourage the patient to make their own decision. I am a less-is-more kind of guy, after all. Plus, encouraging the patient’s decision making can leave behind the pleasing glow of low-grade self-righteousness.

But sometimes things go the other way. You have garden-variety back pain, I tell Ms. X, without any alarm signs that might indicate infection or cancer. Yet she still wants the scan. Or say you come to me and want to check your “basic labs,” to make sure “everything is okay with your blood.”

Neither of these is necessary. MRIs for garden-variety back pain can lead to real harm, as can blood tests for no good reason. And this, the asking for things that I don’t think have a point, is very difficult for me to deal with. I think this because it goes against the grain of my personality (I would rather do less, and avoid iatrogenic harm, than do more and cause it) and such requests reinforce a real, justified expectation that we all have when we go the doctor: we should leave with something, even if it is just a prescription slip. It’s as if the x-ray order or the antibiotic we leave the doctor’s office with is an objective correlative for the care they are supposed to give us.

When the patient asks for something that might harm them without discernible use to me, I try to explain my views — and then people, being who they are, sometimes want to make that same decision. Which leaves me with a range of unpalatable options. I can say no; I can say yes; or I can temporize. Saying no makes me feel good and dissatisfies the patient. Often, if the contraindicated care is provided by a broad range of providers anyway (e.g., antibiotics for viral upper respiratory infections), my refusal does no good. If I say yes I have implicated myself in the patient’s potential self-harm.

Part of a solution, apart from me biting the bullet and saying no more often, is to change expectation, so that leaving the visit “with something in hand” can be not just a script, or a procedure, but a plan of action or a symptom diary to be filled out. Until then, disagreement will still get my hackles up, especially if the patient wants something I don’t.

Zackary Berger is a faculty member of the Johns Hopkins University School of Medicine, where he is an internist and researcher in general internal medicine.  He blogs at his self-titled site, Zackary Sholem Berger, and is the author of Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond.

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  • southerndoc1

    Another point of view:

    “For better or worse, I have come to believe that we—patients, families, clinicians, and the health care system as a whole—would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives. I suggest that we should without equivocation make patient-centeredness a primary quality dimension all its own, even when it does not contribute to the technical safety and effectiveness of care.

    Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.”

    Donald Berwick, Health Affairs, 2009.

    He hasn’t treated a patient in decades, but he sure is great at telling us how to do it!

    • Zackary Sholem Berger

      I think it’s a matter of emphasis. I agree with Berwick’s take, in general, and – as I implied in my piece – I *have* ordered an MRI even when I think it’s a bad idea. Patient-centrism can extend so far. My point, though, is that I feel bad about it, and such feelings of frustration point to conflicts between EBM and patient-centered care. Such conflicts (which you are raising as well in your comment) are important to acknowledge.

      • buzzkillerjsmith

        You swung and and missed with this one, Dr. B. As a practicing doc should should know better. Inappropriate MRIs lead to incidentalomas lead to to more tests lead to pt worry and suffering.

        I am led to understand there is some medical literature on this.

        • Zackary Sholem Berger

          Indeed. And I published some of that. But you know, as a practicing doc, that sometimes you do things that the patient wants and you don’t (cf. your “caving” comments below). My point: there is a conflict here, and it can’t be ignored by either advocates of EBM or of PCC.

          • SarahJ89

            If I may… I avoid doctors like the plague so I’m not adding much to US health care costs. I don’t do physicals, don’t care to add to the data to be mined from my EMR. But about every 18 months or so I do ask for a blood panel to be done, especially as I age. I’d happily pay for it myself if cost was a problem.

            Once in a while yes, there is an incidentaloma. I’m perfectly capable of understanding that phenomena, as are many people. In the case of an incidentaloma, once my PCP and I have discussed it I
            would definitely refuse any further testing as being pointless and
            wasteful.

            But there have also been times when the blood test results are the piece that completes a puzzle.

          • Zackary Sholem Berger

            Thanks for sharing your experience. It sounds like you and your PCP have reached a compromise or some sort of modus operandi. That’s great. I think more of us should do that. There has to be give and take. In general I do not believe in regular blood panels for their own sake. But everyone’s mileage may vary and that’s where the patient-practitioner relationship is vital.

          • SarahJ89

            Dr. B,
            Compared to the CT scan I foolishly agreed to when I was too ill to research the matter I consider my blood panels a cheap thrill.

          • missiedog1

            I too have that relationship with my PCP, my doctor was informed at time of first met, that I made the final decision of all of her orders/suggestions. I very strongly believe all should have that same relationship….it is called communication. I do not believe that all patients must have “SOMETHING” at the end of the doctor’s visit, if there is good communication, which also includes listening on both ends!

    • Zackary Sholem Berger

      Also, sometimes you want someone outside of active care to raise patient-centrism as a necessary point. Those of us in the system can’t see the forest for the trees sometimes.

    • buzzkillerjsmith

      Hilarious. Who is this clown? Oh, the guy who used to run Medicare.

  • http://www.myheartsisters.org/ Carolyn Thomas

    Such an important point, Dr. B. The dilemma you describe is a no-win solution for all. But there’s stakeholder that few acknowledge in this dilemma: other patients. For example, the unnecessary and expensive tests, procedures and scans that are being offered to those whose doctors know don’t medically require them are the same tests, procedures and scans for which patients who really ARE in need must now stand in a queue.

    I say this reluctantly. I’m usually far more concerned about the perils of underdiagnosis and undertreatment, and those whose symptoms are being dismissed and ignored. Yet in heart circles we also know about cardiophobia – the unwarranted belief that a heart attack is imminent – seen in those who “seek continuous reassurance, make excessive use of medical facilities, and avoid activities believed to elicit symptoms”. But cardiophobes can actually affect the care that genuine heart patients get. I wrote here (in “Catastrophizing: Why We Feel Sicker Than We Actually Are” – http://myheartsisters.org/2011/01/05/catastrophizing/ :

    “Those who insist on wasting limited medical resources in search of a high-drama diagnosis that will never come make it so much harder for those of us who actually are ill to be taken seriously by the medical profession. Instead, we may be lumped in with the cardiophobes of the world, dismissed and sent home in mid-heart attack, as I and many other female heart attack survivors have experienced. One wonders how many catastrophizing
    cardiophobes my overburdened E.R. doctor encountered before I
    arrived at his door – and before he sent me home with an acid reflux
    misdiagnosis, just like all those cardiophobic patients get?”

    • Zackary Sholem Berger

      Very interesting. I admit I haven’t thought much about this point, but it speaks to the importance of resource-sparing and Less-Is-More thinking.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This is a much bigger issue than the level of discomfort/frustration experienced by any one doctor/patient.
    If we decide and advertise that patient-centered care is what we want to provide, then we need to put our money where our proverbial mouth is, and acknowledge that following all the explanations/education/conversations, patients are indeed the ultimate decision makers, whether those decisions are cheap, expensive, good or bad.
    Anything that deviates from Dr. Berwick’s definition, be it in good faith by physicians, or in questionable faith by payers, is not patient-centered care.
    You cannot tell people that they are the ultimate decision makers, as long as you approve of their decision, or as long as their decision is cheaper than the alternatives, or they have enough money to cover the difference.

    Of course, this conundrum could have been avoided if we didn’t engage in a large scale advertising campaign to convince patients that they should never trust their doctors. The reality is that those “advocating” for patient-centered care, patient empowerment, shared decision making, or whatever the trendiest buzz word is this morning, have absolutely no intention of actually letting people make their own decisions. The goal here is to remove decision making power from both doctors and patients. For profit, or “savings”.

    • southerndoc1

      Great post. Thanks.

    • SarahJ89

      Patient-centered care is an absurd concept as long as we withhold the information patients need in order to make good decisions–infection rates (with information about the patients’ level of illness so the decks aren’t stack against entities treating the sickest), numbers of procedures done per year by any surgeon, length of time a surgical team has worked together, cost of tests and treatments, the morbidity and mortality stats of institutions and individual doctors (again, in the context of level of illness of patients)–all that stuff that would greatly help but is almost impossible to ascertain when one is well and not available at all when one is ill and in need of a quick decision.

      Nope, we’re left with things like bedside manner and how pretty the curtains were in the examining room upon which to base decisions.

      • Zackary Sholem Berger

        Good point. Both evidence-based medicine and patient-centered care are information-poor.

  • JR

    In my experience there are two kinds of doctors: the dismiss-ers (bad doctors) and the follow-uppers (good doctors).

    I think when a patient wants something done that isn’t necessary; find out the concern and treat the concern. I think in my own experience as a patient, being scheduled for a follow-up appointment (with tasks to do in the meantime) solves the problem of concern.

    For instance, the back pain may be mild and should pass, but the doctor should want to see the patient again and make sure they are improving. In my experience, the good doctors make sure the follow up is in place before the patient leaves. As a patient, I know that if I’m not getting better I don’t have to make that call back to the doctor, and fear the doctor will dismiss me again. It makes me confident I can call the doctor back if I’m getting worse to come back in sooner. It makes me trust my doctor.

    It seems to me (from the outside) many doctors are trained to “dismiss” because doctors are trained in hospitals where they see a patient for something acute. They aren’t trained to think in follow-up.

    • buzzkillerjsmith

      Very well put. Seeing the pt again or at least inviting the pt back if the problem does not resolve helps much of the time and is simply good medicine.

      It doesn’t always work, especially if the pt has to pay a lot to come back, but it often does work in primary care. It is much less effective in the emergency dept. and in urgent care.

      • southerndoc1

        But Buzz, I’m sure you know that if you’re practicing true patient-centered care in a PCMH, those horrible, anti-patient follow-up appointments are absolutely forbidden. Patients just wake up in the morning, decide they want to see Dr. BKJS and come in that morning with a of 20 problems and ten years worth of health maintenance needs, and you and your team handle it all then and there. I find it an extremely reliable method of follow-up to tell my diabetic patients, the depressed ones, the chronic pain sufferers, “Oh, just come back when you feel like it, we’re here whenever you need us.”

        • buzzkillerjsmith

          Oh yeah, I forgot about the PCMH. Strike my last comment from the record.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Follow-up? No way… That’s that volume thing that we must get rid off. It’s about value now. Like southerndoc says, you resolve all 20 problems at once, on demand, and have them email “support” with questions.

    • Shirie Leng, MD

      I think JR has nailed it : trust. Patients who trust their doctors are more willing to take a wait and watch approach. The recent erosion of trust is compounding the over-testing problem. I like the follow-up idea.

    • Anne-Marie

      Having a plan makes me feel like the doctor is working on my behalf and is someone I can trust. It doesn’t necessarily require a followup appointment, a prescription or a CT scan, although sometimes one or more of these might be a component. It’s just the security of having a road map so I don’t feel I’m going to fall off the face of the Earth once I leave the exam room.

      I actually like it when the doctor doesn’t immediately suggest a more aggressive intervention when something conservative, or even nothing at all, might do just as well. I see this as the mark of a thoughtful, careful physician – again, someone worth trusting.

      Don’t give me whatever I want just because I ask for it; give me what you judge to be the best, the most effective and the safest. Most of the time you’ll probably get it right, and if you don’t, I won’t mercilessly smack you around for it, I’ll just let you know there was a problem.

  • buzzkillerjsmith

    Most of the time I can avoid this by talking some with the pt, but sometimes that doesn’t work. Then if it’s a little deal, I cave. You don’t want to get into a tussle at 10 am when you’re working till 7 pm. I notice the younger docs get in many more tussles with pts than older docs like myself .

    But if it’s a big deal I don’t cave. Inappropriate used of opioids is a big deal. Too many CTs is a big deal (radiation). If this kind of stuff goes on and on and on I give the pt his or her walking papers. This is very rare.

    Don’t have to kiss up too much because I don’t work for CorpMed.

    • Zackary Sholem Berger

      Indeed. You too note the conflict between EBM and patient-centered care. My point exactly.

  • DoubtfulGuest

    Good point. I think it’s usually a communication issue. How much do patients really understand about the costs and risks and effects on other patients? We can learn if you’ll teach us.

    I have a weird metabolic disease that causes problems in different systems. Before I was diagnosed, I went through a brief period that I asked emphatically for (not demanded) unnecessary tests, including imaging. I hadn’t found any doctor to think and talk with me about what might be wrong. I was just feeling desperate, hence my “throw the spaghetti to the wall and see what sticks” approach. Terribly expensive, inefficient, and unbeknownst to me, very enmeshed with defensive medicine on my doctors’ end. I didn’t want that! I just needed to know what the problem was.

    • rbthe4th2

      Yes!
      We’ve spent thousands of dollars, when just one fasting blood work round of the tests I had been talking about for months got done. The doc now isn’t happy about doing them but its proven a point and is part to proving another. No offense, underdiagnosis and undertreatment has added to my costs because of being blown off when there was medical justification for testing.
      Some patients actually do know costs and yes, the medical mindset didn’t help. With all due respect, make sure you find out WHY the patient is requesting what they do than call them crazy.
      Randy

  • WWWeaves

    The medical art is to distract the patient whilst nature cures the disease.

    L’art de la médecine consiste à distraire le malade pendant que la nature le guérit. Voltaire (1694 – 1778)