More physicians are having to say “no” to patients these days, thanks to economic and other factors. So much so that I’m beginning to fear physician-patient conflict breaking out across the country, practice by practice.

You have to do the right thing by your patients — and your practice — and sometimes that means saying no. How can you do it in a way that doesn’t annoy them? By starting from a position of caring and mutual cooperation, rather than from a stance of annoyance and frustration.

It may be better medicine not to give an antibiotic for a viral illness, for example, but try explaining that to a patient who insists he wants an antibiotic, clinical evidence be damned. Pay-for-performance programs may encourage good control of diabetes, and may be in the patient’s best interest and good for “the system,” but for physicians it means confronting patients who aren’t controlling their diet or monitoring their glucose.

The recession is also forcing practices’ hands. No, they can’t waive copays anymore. No, they can’t write off a balance. No, it’s not okay if a patient keeps missing scheduled appointments. And, no, really, they don’t want to barter for services. Practices are (justifiably) tightening financial policies just as patients most need some slack.

And then there are the government crackdowns. Consider the internist who e-mailed me recently, worried about Medicare’s RAC audits. He wants to stop billing Medicare patients’ “annual exams” as problem-focused visits. He’s been coding that way for years, so that Medicare will cover the visit and the patients will be happy. But he knows it’s not right. He wants to code a physical — and have his patients pay out of pocket.

Of course, that will annoy patients who think they have a “right” to an annual exam.

What, he asked, should he do?

Whether you are saying no for financial reasons or because it’s in the best interests of the patient, I think it’s where you are coming from that matters most.

Saying “no” to a patient is akin to saying “no” to other sorts of people in your life you’d rather please — a romantic partner, child, or colleague. I really believe that most people respond to intention as much as specifics. What worries me, then, isn’t the internist explaining (or having his office manager explain) that Medicare doesn’t cover preventive exams. That’s easily done with some printouts from the Medicare Web site and a quiet statement of fact. Patients who want the exam can pay out of pocket. That’s just doing upright business.

Similarly, if a physician takes a thoughtful, caring approach to helping a patient, say, manage his diet, that is just practicing good medicine.

No problem.

The trouble starts when, as is often the case, the physician begins from a defensive (or aggressive) position: assuming the patient will never pay, for example, or just wants to be “fixed” by the doctor without ever taking responsibility for his own health.

My sense is that antagonism is infecting the physician-patient relationship more these days. Physicians seem more inclined to assign bad-faith intentions to patient requests, so they assume that taking the high road won’t work. And surely there are some patients like this. But so what? You can still do the right thing and be willing to let the chips fall where they may.

So, if the internist loses some patients who really, really want him to defraud Medicare for their benefit, so what? There are many Medicare patients now who can’t find internists. And lots of them will be happy, truly, to pay out of pocket for an annual exam or just decide they don’t really need one after all.

It’s your business, your risk. Set your policies. Explain and make them clear. And build a practice with patients who want to work the way you do.

That is so much better than building a business around patients you don’t trust and expect to fight with. Physician-patient battles aren’t required.

Pamela Moore is director of content and strategy for Physicians Practice. Are you saying “no” more? Join the conversation in our blog or e-mail me at pam.moore@cmpmedica.com.

This article originally appeared in the October 2009 issue of Physicians Practice.