When it’s hard to say "no"

If you find it hard to say "no" to patients, you are not alone. A recent survey of Avant members identified this as a challenge for 56% of doctors, covering all specialties.

Doctors are expected to only provide care that is clinically indicated and based on their clinical judgement, likely to benefit the patient. However, patients may sometimes have their own ideas about what treatment they expect. It can be hard to decline a patient’s request in a way that maintains a good therapeutic relationship and avoids triggering complaints.

The following techniques can help your patient accept your recommendations.

Listen to the patient

Understand the reason for the request by asking the patient why they are making it. This can help you to find out what else might be going on. Discuss other approaches or treatments, for example physiotherapy or different analgesia options.

Where patients feel heard and respected, even when they do not receive the treatment they requested, they generally report greater satisfaction with the consultation and may be less likely to complain.

In our experience, complaints where the primary issue is a patient not having their request or preferences met, often involve a secondary allegation of disrespect.

Consider carefully and explain your reasons

Once you have asked the necessary questions and have received the patient’s answers, consider your response. Make sure you have not jumped to conclusions about what’s motivating the patient’s request.

If you still believe the treatment is inappropriate, give a firm "no" so there is no misunderstanding. Do so respectfully and offer an explanation using everyday language. Say why you are concerned, or why you consider that the treatment is not in the patient’s best interests.

Keep it professional and stand your ground

Be aware of your own mental and physical state, including being tired, hungry or stressed, and how that might be affecting your reaction.

Also, be mindful that your professional objectivity can be compromised when providing care to someone with whom you have a personal relationship.

Understand any legislative restrictions, for example those associated with prescribing drugs of dependence. This can distance you personally and give you confidence to stick by your decision.

Support your team and manage psychosocial risks

Doctors have sometimes put their foot down with a patient, only to find themselves unsupported by colleagues or practice policies.

From a practice perspective, it's important to think about the psychosocial risks these scenarios can present and consider changes to the design or management of work to help protect staff.

Having policies, and communicating these clearly, makes it easier for everyone to manage patient expectations and reduce the risk of confrontation. Consider how to manage any potential issues if a patient becomes upset, such as training, managing appointment bookings or considering the layout of the practice waiting room.

Document carefully

Document conversations in the patient's medical record, including the reason for declining treatment and any alternatives discussed. Patients who do not get the treatment they were hoping for may ask for a second opinion, or they may complain. Detailed records will help if your decision is reviewed by someone else after a patient complains.

Avant factsheet: Managing difficult interactions with patients

This article was originally published in Connect  magazine issue 20.