Four Steps to Managing Unrealistic Patients

A recent blog by endocrinologist Melissa Young did a good job of expressing a physician's point of view towards unrealistic requests and expectations from patients.  The message was that physicians are human beings, subject to the same constraints of time and space as all other mortals.  They cannot agree to all patient requests for special considerations and survive. 

The blog generated a number of comments, and most of them were angry with patients.  I suggest that is not a good state of affairs -for patients, physicians, or the healthcare industry at large.  Anger begets anger, which is seldom constructive in any way.  I suggest a four-step process to respond to requests for special treatment that will avoid both anger and physician guilt, which leads to even more anger.

Teach your staff to avoid saying "no," especially before they understand the want or need.

The intent of "no" is to shut down the conversation.  It is often appealing to staff and it is almost always a false economy. It’s better to say, "tell me more" or "what are you trying to accomplish?"  I can almost guarantee you that the response to an honest inquiry will take less time than listening to the patient plead, demand, and complain.  It also gives the practice a chance to meet the real need without caving in to the specific initial request.

Make it clear the office wants to help, within the bounds of what it is able to do.

Reassurance that the practice is trying to help the patient with her problem will go a long way toward defusing what could be a tense situation, on both ends of the phone.

Teach staff to limit their comments to "we'll see what we can do."  They must never promise something they cannot deliver.

If there is no place in the schedule for a same-day appointment, don't let staff say "I'm sorry."  This implies an assumption of fault and there is no fault.  It is a morally neutral fact.

Sometimes there are medical, ethical, legal, and/or policy impediments to doing what the patient wants.  These don't require an apology either.  They do require some sort of explanation of the reasoning.  "It's policy" and "it's just the way [the doctor] makes us do it" are not sufficient.  Make sure your staff knows why the requirement serves the patient's well being.

Develop standard protocols for satisfying the most common wants or needs in a way that is, at most, minimally disruptive to the practice.

For any given practice, most requests for special consideration are relatively common.  Think about how you want these handled, write it down, and tell your staff.  Tell them, too, what information you need to make a decision on situations that fall outside the norm.

Emergency prescriptions are a great example.  When can the staff agree to send in an authorization? Will you authorize a month's supply or just a few days?  Under what circumstances must the physician be explicitly consulted first? When must the patient be seen first? What can he do in the meantime?

If you cannot meet the patient's need as requested, offer alternatives.

If a patient is absolutely insistent she be seen the same day, there are several options:

• Work her in, but only if it’s practical and respectful of the day's schedule

• Give her the next available appointment and advice for the interim period, i.e., over-the-counter medication, rest, and what to look for that would signal a need for ED care.

• Suggest an urgent care facility the practice recommends

Try to remember that the real problem is probably more emotional than medical.  It is scary to be sick and not know whether or not it is serious, or to be in pain and not know how long it will last.  Lack of control increases anxiety and viable options relieve it.

Some patients are outrageously demanding.  They need to be asked to find care elsewhere.  Most patients are either unaware or at least temporarily oblivious to what they are asking of the physician or the practice. 

Manage these folks.  Empathize with their situation, but maintain appropriate boundaries.  Respect them as both customers and human beings needing attention.  Respect the needs of yourself and your staff.  Defuse the emotion on both sides of the interaction.