How Should Physicians Handle Irrational Patient Requests?
How Should Physicians Handle Irrational Patient Requests?
There is no question that we are definitely living in a different economic climate today compared to years' past. As a busy clinician in practice, we treat our patients very carefully and of course with great care. There are times, however, when patients ask their physicians for advice, treatments, or other things that are just not necessary.
Just the other day, one of my patients came in for a routine diabetic exam. He is a truck driver and hauls coal for a local trucking company. Unfortunately, his employer informed him and his fellow employees that they no longer would have corporation-backed healthcare insurance. The changes by our current presidential administration have been very unfriendly with coal mining in the southwestern corner of Virginia.
As a result, my patient was now faced with not only having to pay for his office visit out of pocket, but was also faced with having to pay cash for his prescription medications. My patient had previously been very compliant with treatment advice and had never before mentioned any new problems to me. At his last visit, he unloaded a multitude of complaints ranging from worsening peripheral neuropathy symptoms to increasing low back pain. What is worse, he was referencing a prior work-related injury with increased low back pain as a result. After he mentioned each of his complaints to me, his next question was, "...what are my chances of being eligible for disability doc?" How can we answer such a question? I explained to him that a disability determination was based upon a judge's review of his medical records and recommendations from his treating physician. When I informed him that I could not advise him to stop working due to his current medical problems, he became very upset with me.
Another case presented last week regarding a man in his mid 40s that has been "disabled" for several years. He is relatively healthy, has very few medical problems and when he came to the office for his first visit a couple of years ago, I was skeptical regarding how this man could have been approved for disability in the first place.
The request that followed was one for a handicapped parking decal. When I discussed his medical problems with him and explained that handicapped parking spaces are in relatively high demand and in short supply, and further I did not feel that he was eligible for such a sticker. He then quipped back to me, "...but I am disabled and I want a handicapped sticker!" I then informed him that my elderly grandmother in her late 80s does not have a handicapped sticker and he was in better physical condition. Further, I explained to him that based on his medical history and physical examination, there was no reason to justify giving him an order for a handicapped sticker. I do not expect him to return to my practice, but I also refuse to compromise my ethical principles and sign a request for a handicapped parking sticker for a man that is clearly able to park anywhere and further is just as capable as I am of walking through a parking lot. Moreover, I would question his "disabled" status as well.
We frequently get requests from patients asking to be excused from jury duty. More often than not, these patients are clearly able to sit for jury duty, but in most cases they simply do not want to put up with the inconvenience. When I explain to these patients that they have no medical rationale from being excused from jury duty, most of them are OK with that and simply smile and say, "...well it does not hurt to ask."
I saw a new pediatric patient last week transferred from another local pediatrician. The reason for the transfer to my practice was a request for homebound school services. After I went through the patient's history and physical exam, I informed the parents that there was no reason to place the child on homebound status. The parents then became very angry and threatened not to return to my practice. I calmly informed them that there was just no reason to place the child on homebound status. The parents gave me the excuse that the child was being bullied by other students at their school. When I asked the parents if they had previously discussed their concerns with the teacher and principal, they became upset again and left the office while stating "...I guess we will have to look for another doctor."
Our current economic climate is certainly taxing on both patients and physicians. However, the worst thing that we as physicians can do is to enable patients or patient's parents to continue to receive unnecessary medical services or benefits.
My parents raised me to be not only a hard worker, but to be a person of high morals. As I treat my patients as I would want my family members treated, many of them are more frequently becoming upset and irritated. I have never before witnessed such manipulation of the medical system as what I am seeing currently. My fear is that when these disgruntled patients seek treatment elsewhere that their unnecessary demands are being answered by other physicians. How else are we to turn the direction of the medical system if other physicians do not stay consistent with their beliefs and morals?
I fear that the strain on healthcare will continue to worsen as these patients and parents of patients continue to manipulate our system in order to achieve the secondary gain they are seeking.
I too am frustrated by these difficult patient encounters. I work in the urgent care field and patients generally pay a higher co-pay to see us vs. their PCPs. Many demand antibiotics or steroids that are not medically necessary and go against standard guidelines. Despite trying to educate patients on the risks they still want these medications and commonly complain and receive their money back from corporate when they do not get what they want. I wanted to pose a question to providers: When patient's complain they were not satisfied with their care what is your typical response and action?
First I want to acknowledge you for internalizing your parents admirable work ethic and your desire to come from a place of high moral integrity--nice!
I, too, am concerned about the requests I am receiving from patients. I worry that when I refuse a patient's request for whatever reason--their child doesn't need an antibiotic they are demanding or they do not deserve a handicapped placard they want--that they will simply go from to another doctor and keep searching until they get what they want. Pursuing their goal requires medically unnecessary office visits to additional physicians, and each encounter is billed to their medical insurer. The costs for these unnecessary physician visits are then charged to their insurance company or Medicaid or Medicare, driving up the costs of healthcare that are then passed on to us in the form of higher taxes and healthcare premiums.
Lately I've been seeing more patients, many for their first visit, who want me to state they are disabled and sign a form so they can be released from repaying their school loans. The honest ones admit that since finishing school, they simply do not feel like working. Most 'patients' present some vague collection of complaints--many of which probably seem very real to them--to describe why they feel as they do, and prove why I should not require them to work and repay their loans.
Society asks us to be responsible for excusing people from certain requirements--such as jury duty, walking the usual distance to a store from a regular parking place in the parking lot, not showing up to work as scheduled. Historically we have served this role as people of integrity, who possess the requisite knowledge about human health to be able to responsibly adjust society's expectations for someone whose health issues require some degree of accommodation.
But today, as the 'professionalism' of the medical profession continues to decline, I am increasingly frustrated by this issue. I sense that many people just don't respect most physicians anymore, and sincerely believe that since they are paying us we should be giving them whatever they want, be it antibiotics, a disabled placard, or a letter releasing them from taking responsibility for their school loans. Yes, Keith, we physicians must regroup, return to the roots of our calling and present a united front to retake the integrity and professionalism that has hallmarked our respected medical fraternity for 150 hundred years!
-Robb Hicks, MD-
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