Ethics Forum. Sept. 2, 2002.
Scenario: Should you give patients what they want, even if they don't need it?
Many people, concerned by stories they have seen on television or read in newspapers, approach physicians with demands for medical tests or procedures that appear unwarranted. Tales of full-body CT scans that have uncovered tumors or aneurysms have triggered the latest rash of such demands.
How might a physician respond in a manner that both acknowledges the patient's concerns and preserves the patient-physician relationship?
Reply:
Rather than electing to ease a patient's fears by ordering an unnecessary procedure, a physician can address concerns by exploring why the patient wants the test.
Researchers have noted that few physicians urge patients to talk with them about the issues that give rise to apparently unfounded concerns. A seemingly trivial request may be grounded in an actual physical concern. The request creates an opportunity to review information contained in (or missing from) a patient's medical history or in a family history. Often former medical problems or the recently diagnosed illness of a relative are among the reasons for the request.
Physicians should ask whether a particular physical symptom provoked the decision to see the doctor. If so, these symptoms can alert physicians to medical concerns unrelated to the patient's initial request and may indicate more appropriate and specific tests or treatment that is more beneficial than that requested by the patient.
When there is no indication of a medical problem, the physician's role shifts to that of a counselor. In most cases, an empathic conversation with a worried patient can lead him or her to retract unnecessary treatment requests. Many patients appreciate physicians who are willing to use appointment time to talk about symptoms and individualized health matters rather than just explaining the risks and benefits associated with procedures they have requested.
Physicians can use a conversation about the concerns generated by television or newspaper reports to provide accurate information about those health problems and to correct misinformation that the patient may have received elsewhere.
Physicians should end the visit by extending an open invitation for further questions on health-related topics and medical care.
The few individuals who continue to demand unneeded procedures after a discussion with the physician should be discouraged from attempts to find other physicians to order the procedures for them. They might be told, for example, that a physician who agrees to order the test in the absence of any indication for doing so will most likely not be putting the patient's interest first.
Ordering procedures at the request of patients when need is not indicated by exam results can be problematic for a number of reasons. Many such procedures place a significant amount of stress on a patient's body, through exposure to radiation or through the performance of invasive or surgical procedures. Often, the potentially useful information and benefits gained from these procedures is negligible compared with the risks.
Unnecessary procedures also impose financial burdens. Even when individuals can afford the extra expenses associated with patient-requested services, the ordering of unnecessary procedures forces hospitals, insurance companies and managed care groups to cover, at minimum, expenses related to the tests' administration. This practice channels funds that could be used for required treatments away from individuals in need and places undue strain on already overburdened health care systems.
Finally, unnecessary prescription ordering can be detrimental to the patient-physician relationship. Readily meeting patient demands for nonessential procedures furthers an understanding of the patient-physician relation as one that is market-driven, based on a supply of medical care and the demand for it, rather than one that relies on the physician's expertise and experience and is based on a shared goal of preserving the patient's health and wellness.
As persuasive mechanisms of direct-to-consumer advertisement of medical products and services continue to be developed and health care topics are increasingly covered in the popular media, patient concerns about their health will also, undoubtedly, become more frequent and complex. Patients will continue to request tests and procedures that they hear about from others and in the media, even when these tests and procedures are not called for.
Physicians can best respond to worried patients' requests for unnecessary services by paying attention to the complaints and by incorporating patient concerns and health goals into more individualized plans for care.
In this way, physicians can guide patients to seek appropriate, beneficial health care while respecting their autonomy, giving them the information and advice that allows them to make informed medical decisions.
--Kate Thursby
Extern, AMA Council on Ethical and Judicial Affairs
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Scenario: How do you manage a patient who doesn't manage his illness?
Some patients, although they understand the nature of their chronic illness and the consequences of not complying with management strategies, nevertheless don't adhere to diet, exercise and other instructions. This happens even among those who have the financial resources and social support thought to be necessary for compliance. We asked a clinician and psychiatrist who teaches in a family practice residency program what physicians can do to encourage compliance.
Reply:
It's surprising to me how often this situation occurs in our clinic. The compliance literature estimates that up to 50% of medical patients don't understand their illness or its treatment or don't adhere to recommendations for care. I believe the magnitude of this problem is a direct consequence of not spending enough time with patients and not effectively using the patient-physician relationship.
Serious or chronic illness, like grief, requires not just an intellectual acceptance but an emotional adjustment to how the illness changes one's life and self-image. This takes time.
Patients like those in the scenario, however, have come to terms with their chronic illness but don't manage it well.
Let's consider Mr. P, who has accepted he has diabetes. Here, good management by the patient should promote well-being and prevent complications. In our clinic one of the more common reasons for nonadherence is the physician's failure to define responsibilities of both physician and patient for effective care after the acute intervention or diagnosis.
While the patient is acutely ill, the doctor is responsible for treatment and the patient is expected to comply passively. In chronic illness, however, the patient must take charge and learn to manage the problem with help from the doctor. This change in responsibility often needs to be made explicit or the patient, expecting the doctor to continue "fixing," remains passive in relationship to his illness.
I would want to be sure, first, that Mr. P accepts that his doctor cannot cure or single-handedly treat his diabetes. Mr. P must take primary responsibility for managing it, with our treatment goal being not cure, but maximum social function and well-being. If the doctor is more concerned about the chronic disease than the patient, the doctor has a problem.
Assuming that these basics of care have been successfully addressed, the question then is, why doesn't Mr. P take better care of himself? The answer to this question may be surprising, as it was in a case of an insulin-dependent patient of mine with early onset diabetes and poor control. A married, college-educated father of three young children, he confessed that he didn't maintain good control because he used his condition as leverage in his marriage.
His wife, described as controlling and difficult, was responsive to his poor control because her father had died of diabetes. Separating management of his diabetes from marriage problems allowed us to identify better strategies for both sets of problems.
It is always useful to schedule time to sit down with the patients like Mr. P and be sure you understand their side of the story. Nonadherence may be a means of asking for help or, as with my patient, of controlling some other aspect of their lives. The patient may not be readily aware of the function his or her nonadherence is serving. This may only come out after lengthy conversation. In talking, an underlying problem of depression, concern about new symptoms (e.g., impotency) or stress may emerge.
Suppose Mr. P doesn't respond or fit any of the above considerations and has simply decided that sloppy management is what he wants to do because "it's his way." I might suggest that he attend a group for patients with diabetes. Often overlooked, patient groups that meet to discuss chronic illness are excellent for illness acceptance and learning tricks of management, and are supportive in achieving good control.
Finally, a physician who is too frustrated or feels unable to provide Mr. P with medical services in the face of his tepid interest in following suggestions for management might confront him and offer the choice of better compliance or referral to someone more accepting. I would continue to see Mr. P and enjoy having further opportunities to advocate better health habits and maybe better understand his decision.
--Richard A. DeVaul, MD
Professor, Family Practice Residency Program, Texas A&M University College of Medicine and director, Texas A& M Health Science Center's Leadership in Medicine Program
Ethics Forum discusses questions on ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654; fax 312-464-4613. Opinions in Ethics Forum reflect the view of the author and do not constitute official policy of the AMA.
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Copyright 2002 American Medical Association. All rights reserved.
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