Chapter 22. How to respond to inappropriate patient requests?

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

Do not let behaviour of others destroy your inner peace

                                                                        Dalai Lama

Most bad behaviour comes from insecurity

                                                                        Debra Winger

What is meant by inappropriate patient requests?

What is considered to be inappropriate by doctors may be felt most appropriate by patients. So we need to be unbiased when considering patient request as inappropriate. In other words, we need to get into patient’s shoes to be most fair and empathetic. It is doctor’s duty to spend enough time, communicate and counsel properly and answer all questions however silly they may be. This should be the appropriate behavior of a doctor and if not, patients may demand, then it is not inappropriate. Only when we consider request as inappropriate, we must respond appropriately and not argue. Response comes from cerebral cortex while argument is only a knee jerk from spinal level. Response is a result of thought process that spells what is right while argument is meant to decide who is right in which case it becomes an ego issue.

Common requests from patients that are inappropriate

  1. Medical practice is the only profession where patients (clients) expect service at any time of their convenience, even in absence of emergency situation.
  2. Many times, advice is sought on the phone including at any odd hours and is expected to be delivered without seeing a patient, irrespective of its feasibility and of course free of charge.
  3. Cell phones have made it possible to speak to the doctor directly anytime and doctor is supposed to respond to each call, irrespective of being busy with a serious patient.
  4. Every patient expects to be attended in a short time even if he has come later than his scheduled appointment time. After all there are enough excuses to offer for being late.
  5. Majority patients have faith in medicines and tests so they insist to get them irrespective of whether they are required or not. Test results are believed more than doctor’s clinical judgment that may be often questioned.
  6. Test results are sent on WhatsApp for interpretation, instead of patient or his relative bringing them to a doctor and detailed discussion is expected to be delivered on phone.
  7. At times, patient expects a doctor to Interpret results of tests ordered by another doctor or advice on medicines prescribed by another doctor. They expect a free second opinion without seeing the patient.
  8. Every concerned relative or friend of a patient expects latest information about the disease and progress on one-to-one basis and feels it is doctor’s duty to satisfy their queries, as patient is near and dear to them.
  9. Finally, patient may expect concession in doctor’s fees as no hospital, laboratories or pharmacies offer any concession.

How to respond to inappropriate requests?

Most important “mantra” is not to lose temper but still make a point. For example, patient arrives when you are about to leave the clinic, inform him that you are going to attend an emergency and so you would offer him first aid and ask him to report next day. Don’t spend much time or discuss any details. It conveys to a patient clearly that he did not get full advice but at the same time you have attended him and not sent him back without seeing. Wise patient learns not to repeat the same mistake. In modern era of easy communication through cell phone, insist on messages and not calls on cell phone. Cell phone must be used only for emergency situations. However, every patient claims an emergency and so best way is to suggest urgent hospitalization to be on safe side, if they really think is an emergency. Most parents then have said that it is not that urgent. Encourage calls on land-line that can be attended by your assistants and answered accordingly. Assistant can be trained to reply to common queries. Automatically, calls on land-line come during working hours. Remember, Supreme Court expects doctorsnotto offer advice on phone without seeing the patient. Otherwise, doctor is held responsible for the outcome. I have been giving advice on phone all these years but now I add to say this is first aid advice and it is better that patient is seen. So, you are legally safe and at the same time you wish to help patients.

If patients insist on laboratory tests or x-rays, best way is to say that in your opinion they are unlikely to help though patient can get them done if they wish. It takes care of occasional time when such a test proves to be useful though with inconclusive reports, patient knows that he has spent money for nothing. However, if patient asks for specific drugs  like antibiotics that are not required, one must be firm not to prescribe. Many patients ask for tonics and I inform them that it would be useless so I won’t prescribe but as it is harmless, they can decide to take it. If they insist, prescribe it.

After all, manufacturer and chemist also must earn and everybody will be happy thereafter. If I am asked to opine on prescriptions or test results ordered by another doctor, inform the patient that correct interpretation is possible only with correlation with physical examination. Most doctors don’t document their physical examination findings and so it is not fair for you to offer advice merely on test results.

In serious situations, every close and not so close relative and friend wishes to get first-hand information from treating doctor. Best way is to request immediate guardians to take care and if they wish, you should be ready to talk to all of them at one time.

Personal notes

Our joint practice helps patients to contact one of us almost through 14 hours of working day from 8 am to 10 pm. This saves us from untimely requests from the patients. If occasional parent insists on unnecessary tests, I document my advice and leave it to them to undergo the test.  There is no point in making an issue of it. However, demand for an unjustified antibiotic is not accepted and opinion to that effect is documented. At times, parents have objected to  accept prescription of steroids even when scientifically indicated and in such case, I would document my advice and its justification but leave it for parents to follow or not. After all patients have autonomy but if they don’t follow youradvice, you are not responsible for the outcome. Once a VIP parent wanted me to see their child at odd hours even when there was no emergency and so I refused. It upset them and they never came back to me. I consider it as their loss and not mine.

Take home message

Consider patient request with due allowance to their fear or concern about the disease or treatment. So, within limits, what is inappropriate to a doctor may be most appropriate to a patient. Inappropriate requests must be handled with care, calmness and diplomatic way to avoid bitterness and arguments. At the same time, show gentle firmness in your opinion. Remember patient has a right to his own views and so we should leave it to him to decide whether to follow your advice or not. So be flexible to a large extent especially when patient’s demands are harmless though may also be useless.

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