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When You Have To Tell Demanding Patients ‘No’

Residents are required to take care of patients, follow orders and execute someone else's plans. They always have the guiding safety net of the attendings, who truly call the shots.

The moment residency is complete and it is your first day of work, everything changes. The patients are yours. The diagnosis is the one you make and you set the treatment course. Most of the time, the patient respects your knowledge and trusts your plan. Occasionally, you get the patient who tries to control the visit: the “demanding patient” (8 percent of patients, according to a recent article by Gogineni and colleagues).1 You perceive demanding patients as attempting to overpower you, thinking they can call the shots and dictate their treatment. They should not. You cannot let them. You may feel such patients misconstrue your youth for weakness, lack of knowledge and experience, ultimately blurring the roles of the doctor-physician relationship.

You see these patients as having strong demands and who want to use you as the vehicle for their “needs.” This can turn into a difficult situation with the back and forth. They demand something and you give your rebuttal. They further demand and now distrust. You become frustrated and feel angry/belittled. This ping-pong game continues and you ultimately give in to the patients’ demands. It appears to be a no-win situation.

It is your task as a professional and a specialist to take the time, and truly find out what the patient wants and expects from the visit. Do not get caught up in "giving the people what they want," a phrase I sometimes found myself falling back on during fellowship with a frequent patient population. Although this can be the easy option, it is no way to start your career. “Give the people what they want” is not always the right thing for the patient and I regret this past attitude of my naïve days.

Often, the patient’s demands are a mask for some other issue. Maybe what you perceive as a demand is a reflection of your communication skills. We have all spent many years perfecting our technical and diagnostic skills, but much less time working on skills that we cannot read about in a textbook or journal (social, communication, emotional). Be calm and take the time to listen to the patient. Question the patient in a non-accusatory way and keep the channels of dialogue open. Say “no” without being negative or better yet, give a well thought-out reason/rationale why “no” is your decision. A patient who understands and is on board with the plan is a patient who is more likely to be adherent.

Trust is the most important component of the doctor-patient relationship and preservation of this trust is paramount. Some tips include understanding the underlying cause for patients’ demands/actions, setting boundaries and communicating openly and honestly. Deep down, patients are looking for guidance and information, and to be treated as individuals. Is that not why we became physicians? Greater patient satisfaction can happen through incorporating some of those non-technical skills such as engagement, empathy, education and enlistment during our patient interactions.2

My residents upon graduating got me a mug that says, “I do what I want.” More important than doing what you want is doing what is right. You will find that in being a new doctor there are many things out of your control. The one thing you should always have complete ownership over is how you treat your patients. Therefore, take this privilege wholeheartedly and use it for good. You may have sacrificed many things over the last eight to 12 years of education: holidays with the family, weddings, vacations, money, sleep. The list goes on. Do not sacrifice your integrity, morals and pride in your work.

References

1.      Gogineni K, Shuman K. Patient demands and requests for cancer tests and treatments. JAMA Oncol. 2015;1(1):33-39.

2.      Chesanow N. The art of handling difficult patients. J Med. Available at https://www.ncnp.org/journal-of-medicine/1580-the-art-of-handling-difficult-patients.html . Published July 1, 2015. Accessed September 1, 2016.

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