The 'Angelina Jolie effect': Her mastectomy revelation doubled NHS breast cancer testing referrals - Google video

The 'Angelina Jolie effect': Her mastectomy revelation
doubled NHS breast cancer testing referrals

Google video

Handling Patient
Demands
       MAJ/P Elizabeth Duque, MD, MBA
       USAFP 2015

Dilemma
1.   Media, Celebrities, Internet
2.   Doctor – patient relationships
3.   Customer service focus
4.   Culture of society
5.   Limited time
6.   Ethics

Conflicting ethical
considerations

• Patient autonomy versus professional integrity

• Autonomy versus do no harm (risks and benefits)

• Cheating versus justice (stewardship)

Case Studies
1. A 28 year old female comes in requesting her
   “annual blood work”.

2. A patient comes in demanding a referral to
   neurology for headaches. She has never been
   evaluated or treated for them before.

3. A patient comes in requesting Vicodin for back
   pain? What if it were Celebrex?

Some data
• 24% of physicians view patient requests as positive
• 43% view them as having a negative impact on patient care and
  interactions

• More than 10% of patients will make a request for a specific
  medication

  •   19.8% of patients will receive a narcotic if they request on
  •   1% will receive a narcotic if not requested
  •   53% will receive Celebrex if requested
  •   24% will receive Celebrex if not requested

• 85% of ER providers ordered CXR if requested, even thought 0%
  thought it was clinically indicated

How do you respond?

Before Responding
                SELF AWARENESS

• Understand your own biases

• Challenge your initial assumptions

Before Responding
       Understand the Patient’s Request

• What is the context of the request
• What is the authenticity of the requests
• What is the underlying concern
• What assumptions/biases does the patient bring

Before Responding
             Know Your Bottom Line
• Set boundaries

• For what will you fall on your sword for?

• Patients cannot insist on treatment that is
  against your clinical judgment

Before Responding
               Consider Alternatives
• This is where prep work becomes important?

• Can you seek a consensus with the patient?

• Are there research opportunities or other
  sources for the patient to be involved in that
  would meet the patients needs?

Case Studies
1. A 28 year old female comes in requesting her
   “annual blood work”.

2. A patient comes in demanding a referral to
   neurology for headaches. She has never been
   evaluated or treated for them before.

3. A patient comes in requesting Vicodin for back
   pain? What if it were Celebrex?

Responding

Summary
• Patient demands are common and can challenge
  providers
• There is no set way in which to respond
• Appeal to authorities (organizations, guidelines,
  etc…)
• Listen and work with patient
• Continue to emphasize with patient
• Maybe is often the best answer but hardest to
  get to.

QUESTIONS?

References
•   Asscher, E., Bolt, I., & Schermer, M. (2012, June). Wish-fulfilling Medicine in Practice: a Qualitative Study of
    Physician Arguments. Journal of Medical Ethics, 38(6), 327-331.
•   Ballard, D., Reed, M., Wang, H., Arroyo, L., Benedetti, N., & Hsu, J. (2008, December). Influence of Patient Costs
    and Requests on Emergency Physician Decisionmaking. Annals of Emergency Medicine, 52(6), 643-650.
•   Brett, A. S., & McCullough, L. B. (2012, January 11). Addressing Requests by Patients for Nonbeneficial
    interventions. Journal of American Medical Association (JAMA), 307(2), 149-150.
•   Burger, I. M., & Kass, N. E. (2009, April). Screening in the Dark: Ethical Considerations of Providing Screening Tests
    to Individuals When Evidence is Insufficient to Support Screening Populations. The American Journal of Bioethics,
    9(4), 3-14.
•   Ferrante, J., Shaw, E., & Scott, J. (2011, October). Factors influencing Men's Decisions Regarding Prostate Cancer
    Screening: A Qualitative Study. Journal of Community Health, 36(5), 839-844.
•   Gregory, S. (2005, May 19). Preparing for Practice: Difficult Patient Requests. Update, 70(5), 80-84.
•   Henry, L. A. (1998, September). Demand Management: The Patient Education Connection. Family Practice
    Management, 5(8), 65-70.
•   Lorenzetti, R. C., Jacques, C. M., Donovan, C., Cottrell, S., & Buck, J. (2013, March 15). Managing Difficult
    Encounters" Understanding Physician, Patient and Situational Factors. American Family Physician, 87(6), 419-425.
•   Maizes, V. (2000, February 1). Setting Limits on Demanding Patients. American Family Physician, 61(3), 881-882.
•   Malm, H. (2009, April). On Patient Requests for Unproven Screening: Dim Guidance for Screening in the Dark. The
    American Journal of Bioethics, 9(4), 15-27.
•   McKinlay, J. B., Trachtenberg, F., Marceau, L. D., Katz, J. N., & Fischer, M. A. (2014, April). Effects of patient
    Medication Requests on Physicians Prescribing Behavior: Results of a Factorial Experiment. Medical Care, 52(4),
    294-299.
•   Paterniti, D. A., Fancher, T. L., Cipri, C. S., Timmermans, S., Heritage, J., & Kravitz, R. (2010, Feb 22). Getting to "No".
    Archives of Internal Medicine, 170(4), 381-388.
•   Silberstein, N. (2010, January). Understanding and Managing Patient Expectations. Podiatry Management, 109-
    112.
•   Toiviainen, H., Vuorenkoski, L., & Hemminki, E. (2005, March). Physicians' Opinions on Patients' Requests for
    Specific Treatments and Examinations. Health Expectations, 8(1), 43-53.