'But I need this procedure!'

Patients increasingly view the provision of healthcare as a service – and doctors as the service providers who must meet the patient’s needs and in some circumstances, demands.

This can put doctors in a difficult position, as one obstetrician member found when faced with managing a patient demanding a caesarean. The doctor’s refusal to schedule the caesarean resulted in a complaint to the Health Care Complaints Commission, which was discontinued with no findings made against the doctor.

Patient makes complaint against member

A patient who was in their third trimester presented at the local hospital clinic. At a previous appointment at the clinic, the patient discussed with a registrar the option of having a caesarean and had come in that day to schedule the procedure.

Upon meeting with the consultant obstetrician, the patient was surprised to hear the doctor say they wouldn’t recommend the patient undergo a caesarean due to a previous abdominal injury she had sustained.

The patient told the consultant the procedure had already been approved, so she wouldn’t be leaving until they scheduled it in.

In looking to de-escalate the situation, the consultant reviewed the patient’s file and confirmed that while they could see there was a discussion about the procedure, it had not been approved as yet by a consultant as per protocol.

The patient angrily responded “It was definitely approved. If you won’t book me in, I’ll go to someone else who will!”

Taken aback by how agitated the patient seemed, the consultant tried to get to the bottom of why they were so insistent on the caesarean but could not get an answer except that it was necessary she have one.

The consultant became increasingly concerned about the patient’s inflexibility to consider other options and arranged counselling for them.

The patient then made a complaint to the Health Care Complaints Commission stating the member refused to book in a necessary caesarean and they had failed to properly communicate why they wouldn’t book her in.

A solicitor and medical adviser assisted the member with their response to the complaint. The complaint was discontinued at assessment stage by the Health Care Complaints Commission and Medical Council because they did not identify any issues of clinical concern or risks to public health and safety.

What to do when a patient is insistent

First, determine if the patient is demanding a procedure because they don’t fully understand it is inappropriate or if there is another reason, such as a fear of different treatment.

Ask the patient questions to gauge comprehension, address gaps in their understanding and provide resources, such as a brochure.

Avoid using jargon and pay attention to body language which may hint the patient doesn’t quite know what you are talking about. Giving the time to go into detail about alternative options can also help reduce anxiety.

At the end of the day, doctors have very different obligations than other service providers, the most important of which is to act in the best interests of the patient’s health.

If you have done all you can to inform the patient of the treatment options and addressed their concerns, it may help to refer them to another doctor for a second opinion. If the patient is still not happy, you can escalate the matter as a complaint to the hospital’s management.

Case comment

In this situation, the fact the consultant had detailed notes about the incident was a strong risk mitigation strategy and made it easier to address and defend the patient complaint. While the consultant was only stating the facts and hospital protocol, the patient interpreted the situation as the doctor questioning their honesty and denying them necessary care. The doctor was able to demonstrate that they had explained to the patient why the treatment option wasn’t ideal and that they had communicated this appropriately.

However, it's important to keep in mind a patient may not interpret what you say in the way you expect them to. In terms of managing the patient’s emotional state, it may have helped to reaffirm the doctor wasn’t questioning their honesty and to have explained their hands were tied in following the hospital’s protocols.

Useful resources

• Complete our webinar: Insights and strategies to manage difficult patient situations.
• Factsheet: Managing difficult patients.
• Factsheet: Compensation claims and complaints insights: O & Gs