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We don’t have to agree but it doesn’t have to end in tears

I told him NO. You don’t need antibiotics you have a virus. Now leave.

This is the rather macho way in which the story of how a patient’s ‘unreasonable’ request was rejected is sometimes recounted. In some cases the law was changed to allow people to access some items much more readily:

In some countries, potent drugs are now losing their efficacy because of unregulated access. The stage is set for disagreement and inevitably it comes when the provider does not have a plan for how to tackle the request that is not in the patient’s best interest or does not address associated risks that patient is taking. Arguments might be even more common were it not for the evidence that healthcare providers sometimes act without assessing the requests fully. This makes matters worse because it raises unreasonable expectations. In one recent study it was reported:

In spite of the requirement that pharmacists sell restricted medicines, shoppers often found it difficult to distinguish pharmacists from other pharmacy staff. Shoppers were able to confirm that a pharmacist was definitely involved in only 46% of visits. In 8.8% of the diclofenac visits, and 10.8% of the visits for vaginal anti-fungals, no counselling was provided. The vaginal anti-fungal visits tended to be more product-focussed than the diclofenac visits. When they purchased diclofenac, most pharmacists asked shoppers if they had, or had had, stomach problems (74.6%) or asthma (65.4%). A minority asked about the symptoms of the vaginal fungal infection which the female shoppers presented with. While most pharmacies recorded patient names, many did so in a way which compromised patient confidentiality. Pharmacy World and Science

Similarly, it has been shown that performance varies in general practice:

In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options—that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a ‘prescription only’ or ‘referral only’ option. They were less likely to manage prostate cancer with a ‘prescription only’, yet more likely to manage it with a ‘referral with investigation’. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a ‘referral only’ or a ‘referral with investigation’. BMJ open

In summary:

  1. People often present with ideas that are at odds with those of the provider.
  2. The law sometimes enshrines the right to over the counter treatments that may not be indicated or may actually harm people.
  3. Patients are not appropriately assessed in all cases which mean they either acquire things that are not appropriate or denied things that are.

Once the decision is made to say no it isn’t always handled well. This has also been demonstrated in the literature. What has been published suggests that one of the most potent tools in the armory are good consultation skills. The more worrying issue is how this comes as news to some in a profession that pride itself on members’ ability to communicate. The bottom line is that any business that loses the relationship with its clients is heading for the rocks. Every business knows that there are polite ways to reject a customer. Therefore the answer to the question of whether and what to prescribe is a function of the consultation skills taught to every medical graduate. The issue at stake when things go wrong is how well those skills are being exercised. The quote at the top of this post suggests that some doctors need a refresher.

Picture by Jens Karlsson

Comments

  1. Ian Watts says:

    I’m a believer in teaching the micro-skills for ‘breaking bad news’ and having ‘crucial conversations. They are useful in saying ‘No’; or “I’ve noticed a potential issue with patient safety.” or “I feel uncomfortable when you use sarcasm to make a point,” …
    They are fundamental in exploring sensitive issues – the cuts across the leg which a colleague saw recently, the bruises on a young boy, the driving of the independent 85 year old….
    The skills can be taught and practised.

  2. Robert Olcott says:

    One hundred years before I arrived in New Hampshire, 85% of the land surface was ‘Agricultural’. One hundred years later it was ‘Forested’…
    I awoke one morning, about a year ago, …to find a Deer Tick in my underpants–apparently I’d managed to fall asleep, sleep well all night, and awoken to use the toilet, and found the Deer Tick in the center of my undershorts.
    Being on Medicare, and knowing the risk of Lyme Disease, I went to the local “Urgent Care” medical clinic, as I couldn’t get an ‘urgent’ or ’emergency’ appointment at my Primary Care provider, and wished an examination of areas I couldn’t see, and/or a blood test. I couldn’t understand later why Medicare didn’t cover the cost of the ‘urgent’ exam or the blood test… But I’m grateful to the doctor and staff there.

  3. Robert Olcott says:

    One hundred years before I arrived in New Hampshire, 85% of the land surface was ‘Agricultural’. One hundred years later it was ‘Forested’…
    I awoke one morning, about a year ago, …to find a Deer Tick in my underpants–apparently I’d managed to fall asleep, sleep well all night, and awoken to use the toilet, and found the Deer Tick in the center of my undershorts.
    Being on Medicare, and knowing the risk of Lyme Disease, I went to the local “Urgent Care” medical clinic, as I couldn’t get an ‘urgent’ or ’emergency’ appointment at my Primary Care provider, and wished an examination of areas I couldn’t see, and/or a blood test. I couldn’t understand later why Medicare didn’t cover the cost of the ‘urgent’ exam or the blood test… But I’m grateful to the Urgent Care doctor and staff there.

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