Telling patients “no” is not always easy. Primary care physicians (PCPs) especially know this all too well. In addition to “keeping the peace” with patients and avoiding conflict, providers may feel pressure to obtain better patient satisfaction scores, knowing that their status and/or compensation, in part, may be linked to higher scores.
How do you tell such patients “no” in a way that minimizes conflict and reducing the risk of your being dissed online, receiving a low score on a patient survey, or inciting the patient to switch physicians?
Couch a No in an Explanation–Telling a patient, “No, you can’t have that drug, test, study, or appointment,” maximizes the odds that the news will not go over well. There’s a more diplomatic, less confrontational way to achieve the same result. Instead, try saying, “Okay, we can consider your request, but let me tell you what I recommend and why I think that will be better for you.”
Open a Discussion– When a patient makes a request that you’re not willing to accede to, you can diffuse potential conflict by taking time to understand the “why” behind the patient’s request. They likely have something they’re worried about. You have to peel that back. Ask yourself, “What is it the patient is really seeking?”
Be Willing to Negotiate– Your willingness to engage in a give and take dialogue with the patient can make ultimately going against the patient’s wishes much more palatable than a flat-out no. Deferring a final decision may also be helpful: “I know we are not on the same on this matter, but let’s think about this some more and we can discuss again at your next appointment.
Be a Cheerleader– Turn a hard “no” into a soft one by offering alternative perspectives, reinforcing aspects of their situation that are going well and that avoiding the potential risks and costs of unneeded medications, treatments or studies.
Use a Good Cop/Bad Cop Routine– Referring the patient to a colleague for a consultation about the appropriateness of the request can be a useful strategy—the expert consultant’s negative response to a questionable “ask” will often neutralize the impact of a “No” response. Having your nurse or assistant who is prepping your patient ask them if they have any special requests may also be helpful both to prepare you for an inappropriate “ask” and they may also be able to advise the patient that, while you will ultimately decide how to respond, that it is not your practice to comply with requests that are outside of the standard of care.
Always Lead with Empathy– Patients go to see the doctor for a variety of emotional and complex reasons. One of them is to be acknowledged, respected, and understood. This is often more important than having their request for a specific medication or test fulfilled. Let them know that you’re saying no is because you sincerely believe that having their request filled will not be in their best interest.
Deflect the Blame–There are times when you need to say “no” to a patient because the “ask” is beyond your capacity to fulfill. Explaining the external barriers interfering with the patient’s desires will diffuse their frustration or anger with you. For example, when a patient asks for an expensive and otherwise unnecessary test or treatment, you could say, “I can try to get that approved by your insurance, but I know from past experiences, it likely will not happen.”
When Necessary, Be Firm– Most of the time, if you do it diplomatically, patients will take “no” for an answer and still appreciate your concern for their well-being. But sometimes they won’t. In those instances, put your foot down—but gently. “First, do no harm” comes in many shapes and folks will respect your firm commitment to their welfare knowing that your decisions are based on their best interest.
At the end of the day, it’s all about letting patients believe that they’ve been heard and considered. The flat out “no’” answer takes away their dignity. It takes away their feeling of self-worth and pride. We need to be sure that they know of our respect for them and that we honor the privilege to be their care providers even when there is disagreement about the way forward.