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  • Drop it into MD Drop it into MD 
    Participant
    Status: Physician
    Posts: 440
    Joined: 09/20/2018
    Earnest refinancing bonus

    I thought this would be a good community to get a diversified opinion.

    I am not a people pleaser. (except with my wife) I do not pretend to agree with or go along things that I actually do not and that translated to my work when I am pretty hard with giving out antibiotics for short course likely viral illnesses, extended work notes for nonsense, opiates for non severe pain, support animal letters, notes to get out of jury duty etc. The list can go on.  I try to give a fair and balanced approach but as you all know so much is subjective that people take it personally when they are refused something.

    We do patient satisfaction surveys like most others.  I am trying to actually use them to improve my patient care.  What my real question here is;

    How do you say no nicely.

    What tactics have you more seasoned docs developed to help you convince patients that they do not actually need X.  I want to make people happy but I also want to do a good job as a physician to my patients and to the community.

    Thank you in advance for all your sage advice/comments.

     

    #178239 Reply
    Avatar hospitalist md 
    Participant
    Status: Physician
    Posts: 91
    Joined: 10/31/2017

    I am a hospitalist ,so i don’t face a lot of the above issues frequently. That being said… i do have to deal with quiet  a bit of pain med requests and antibiotics and such… I usually say that a particular treatment that the patient is requesting does more harm than good and that their safety is paramount to me and so its not advisable to prescribe said antibiotic or pain med .. list side affects like c.diff for too much antibiotic use, respiratory depression from excessive opiate use etc etc…

    #178244 Reply
    Liked by SLC OB, hatton1, LizOB
    Avatar Peds 
    Moderator
    Status: Physician
    Posts: 4636
    Joined: 01/08/2016

    Patients don’t care. You say no, they will be unhappy. The intelligent ones will move on.

    Avatar Tim 
    Participant
    Status: Accountant
    Posts: 3286
    Joined: 09/18/2018

    Listen. Now why would you need that honestly? Smile. Everything in your decision making is really intended to be in the patient’s best interest and those around them.

    -Contagious, don’t go to work.
    -Support animal letter, not practical if the next seat has a support German Shepherd. If they need it, fine. It’s not your pet I’m worried about.
    Facts matter, here is why this is best for you. Are we on the same page?

    #178246 Reply
    ENT Doc ENT Doc 
    Participant
    Status: Physician
    Posts: 3567
    Joined: 01/14/2017

    If you can see they have no desire to consider the evidence and are pushing for a specific treatment I would empathize and deflect.  “My prescribing patterns and antibiotic use are not dictated by me, actually.  It frustrates me to no end, and I’m sorry someone else has come between us in providing care.  The higher ups at the hospital and government look at this stuff.  The experts in my field have reviewed all the literature and have written practice guidelines on this, which are then looked at via quality initiates by my bosses and the federal government…”  That way you can both (sort of) get mad at some other boogyman not in the exam room, and you’re not lying.

    MPMD MPMD 
    Participant
    Status: Physician
    Posts: 2582
    Joined: 05/01/2017

    I have the potentially unpopular opinion that patient satisfaction surveys are kind of a bogeyman. I’m ready to be piled on if I’m wrong.

    I’ve been on staff at lots of different places and I work in EM, a specialty that is supposed to be one of the primary victims of satisfaction. I’m far from a pushover on things like work notes, narcs etc. I have barely ever heard about my satisfaction scores except for once quarter when I was the highest in the group or something like that. I’ve been all over the place it isn’t like I’m always at the top.

    Curious to hear if people are really seeing compensation affected by this. If so I would do one of 2 things: 1) work within the incentives provided within reason, 2) do my thing and just deal with the slight hit in revenue. If your job and/or comp is really that affected by satisfaction you might have kind of a crappy job?

    As others have said if a patient has a particular desired outcome and you don’t provide it I think you could waste an hour trying to justify and still get hit on a survey. I think if I were in primary care I might have a lower threshold than some to invite certain pts to find a new provider more aligned with their short and long term health care goals.

    @ENTdoc that’s an interesting strategy but I doubt it works. I do fall back on things that I never do from time to time e.g. I do not refill narc rx but that’s usually more to stave off conflict rather than try to preserve survey numbers.

     

     

    Edit: to OP when I do urgent care shifts (rare now) and deal with the “here for abx” complaint I would usually just be really direct and say something like, “my experience is leading me to think that your goal for today is to get an antibiotic rx, I don’t think that’s appropriate and I think it’s potentially harmful but I also recognize that you can go to Walgreens and just get them. if you want to make this quick just tell me that’s why you’re here and let’s just discuss the risk/benefit of that particular issue.” If they told me they were going to go straight to WG if I didn’t give them rx I would usually just write it and then document that I clearly advocated a “wait and see” strategy like we sometimes do w/ OM in kids.

     

    #178251 Reply
    Liked by Tim
    Zaphod Zaphod 
    Participant
    Status: Physician, Small Business Owner
    Posts: 6323
    Joined: 01/12/2016

    I thought this would be a good community to get a diversified opinion.

    I am not a people pleaser. (except with my wife) I do not pretend to agree with or go along things that I actually do not and that translated to my work when I am pretty hard with giving out antibiotics for short course likely viral illnesses, extended work notes for nonsense, opiates for non severe pain, support animal letters, notes to get out of jury duty etc. The list can go on.  I try to give a fair and balanced approach but as you all know so much is subjective that people take it personally when they are refused something.

    We do patient satisfaction surveys like most others.  I am trying to actually use them to improve my patient care.  What my real question here is;

    How do you say no nicely.

    What tactics have you more seasoned docs developed to help you convince patients that they do not actually need X.  I want to make people happy but I also want to do a good job as a physician to my patients and to the community.

    Thank you in advance for all your sage advice/comments.

     

    Click to expand…

    They cannot be used to improve pt care, ie, their medical condition. All data and common sense shows otherwise. Dont even try it.

    You’re job isnt to make people happy, its to make them healthy. Obviously theres a balance there, but remember the priority one.

    My favorite thing about all the narcotic stuff lately is things are legitimately out of our hands, we can just say the state says no way you cant have them, entered into a database, etc…

    #178255 Reply
    Zaphod Zaphod 
    Participant
    Status: Physician, Small Business Owner
    Posts: 6323
    Joined: 01/12/2016
    @ENTdoc that’s an interesting strategy but I doubt it works. I do fall back on things that I never do from time to time e.g. I do not refill narc rx but that’s usually more to stave off conflict rather than try to preserve survey numbers.

    Click to expand…

    It definitely works because people know its true.

    #178258 Reply
    Drop it into MD Drop it into MD 
    Participant
    Status: Physician
    Posts: 440
    Joined: 09/20/2018

     

     

    Edit: to OP when I do urgent care shifts (rare now) and deal with the “here for abx” complaint I would usually just be really direct and say something like, “my experience is leading me to think that your goal for today is to get an antibiotic rx, I don’t think that’s appropriate and I think it’s potentially harmful but I also recognize that you can go to Walgreens and just get them. if you want to make this quick just tell me that’s why you’re here and let’s just discuss the risk/benefit of that particular issue.” If they told me they were going to go straight to WG if I didn’t give them rx I would usually just write it and then document that I clearly advocated a “wait and see” strategy like we sometimes do w/ OM in kids.

     

    Click to expand…

    What antibiotics can you just go to walgreens and get without a prescription?

    @ENT I do try that.  It does work sometimes.

    @peds to the point as always and I do agree.  I am surprised with how many patients who do not get along with me for these reasons stick with me and expect a different outcome next time.  I guess changing physicians must be more of a pain then getting what you think you want.

    @zaphod I agree they do very little to improve our ability to provide care but I am hoping to improve my ability to communicate.  Because if they truly understand what I understand then there would be no argument.  I do not think there is an answer but I thought it might be a good discussion.

    #178270 Reply
    Avatar familydocPA 
    Participant
    Status: Physician
    Posts: 67
    Joined: 03/03/2017

    As someone who is on the review board for the patient comments that get posted to our public website (almost always unedited), I have a massive love/hate with this system.

    I love that it gives patients a voice in a way that most docs are not used to hearing. Patients have been subjected to a terrible healthcare system for a really long time, with no recourse in a system full of uncertainty, lack of transparency, and at times outright poor treatment.  A lot of docs are not used to hearing this type of feedback, and are quick to say “I can’t be responsible for xxx, it’s not in my scope of practice.”  Yet when they see these comments, we inevitably see a shift in how they provide care to make positive changes.  It allows for some recognition that we are responsible for ensuring that our patients are guided through the system, not just that we gave recommendations/orders that they may or may not have understood.

    Of course, part of me really hates these comments.  It gives a voice for a whiny populous to scream about not getting what they want.  I fear that our culture has long shifted from seeking docs for advice, to a preponderance of seeking us as medical vending machines.

    For this reason, I always say that I’m most scared of the docs in the community that have the highest satisfaction scores.

    But to answer your question, things I have found personally to help me in saying “no”:

    -Giving an indication of my opinion long before the end of the visit. For example, a new patient with pain talking about how opioids were stopped by their last doc, interrupt immediately with the phrase “that’s great!  We definitely don’t want you to be on those.”

    -It sounds obvious, but really listening to the person’s concerns (even if you want to sarcastically ask the 45 year old if they’ve never experienced a cold before)

    -I used to do lots of citing medical evidence, guidelines, etc, – but I do this much less often now. I found that this does very little to persuade people from whatever they are certain they need.

    -I do plenty of normalizing, and avoid loaded medical jargon. Say “chest cold,” not bronchitis.  Say “head cold,” not sinusitis.  “When people get a bad cold that moves into the chest, I completely expect it to last 2-3 weeks. This is normal and does not mean that you need an antibiotic.”

    I have found the most difficulty with the antibiotic issue, because of the sheer number of overprescribers available in the community.  It really gives confusing expectations to people, but I do not let if affect the quality of my care.

    #178272 Reply
    Avatar familydocPA 
    Participant
    Status: Physician
    Posts: 67
    Joined: 03/03/2017

    Btw our med group does tie compensation to surveys – I do not think that it is helping burnout (but does seem to boost our national rankings)

    #178273 Reply
    MPMD MPMD 
    Participant
    Status: Physician
    Posts: 2582
    Joined: 05/01/2017

     

     

    Edit: to OP when I do urgent care shifts (rare now) and deal with the “here for abx” complaint I would usually just be really direct and say something like, “my experience is leading me to think that your goal for today is to get an antibiotic rx, I don’t think that’s appropriate and I think it’s potentially harmful but I also recognize that you can go to Walgreens and just get them. if you want to make this quick just tell me that’s why you’re here and let’s just discuss the risk/benefit of that particular issue.” If they told me they were going to go straight to WG if I didn’t give them rx I would usually just write it and then document that I clearly advocated a “wait and see” strategy like we sometimes do w/ OM in kids.

     

    Click to expand…

    What antibiotics can you just go to walgreens and get without a prescription?

    @ENT I do try that.  It does work sometimes.

    @peds to the point as always and I do agree.  I am surprised with how many patients who do not get along with me for these reasons stick with me and expect a different outcome next time.  I guess changing physicians must be more of a pain then getting what you think you want.

    @zaphod I agree they do very little to improve our ability to provide care but I am hoping to improve my ability to communicate.  Because if they truly understand what I understand then there would be no argument.  I do not think there is an answer but I thought it might be a good discussion.

    Click to expand…

    WG minute clinics

    #178274 Reply
    Zaphod Zaphod 
    Participant
    Status: Physician, Small Business Owner
    Posts: 6323
    Joined: 01/12/2016

    Just because you know you’re position is correct (on a probability basis, not in certain terms ofc) you certainly can deliver the message with empathy and understanding. Its really all in how its handled, in most situations there wont ever be a need to be gruff or seem like your defending a position strongly. Every now and then yes, but rare.

    One thing I often do not necessarily med specific, but in general management is tell the patients this is my feeling based on your signs/symptoms right now, if it evolves or does not improve I absolutely want to know and will change course if that arises. Makes your position seem less rigid and willing to do what they feel might be necessary.

    I cant imagine trying to discuss something like guidelines, etc…you’re not going to breach the emotional/fear side of people with a rational/cerebral discussion without first addressing their fears so they can think clearly.

    #178280 Reply
    Avatar Tuxedo 
    Participant
    Status: Physician
    Posts: 38
    Joined: 02/20/2017

     

    @peds to the point as always and I do agree.  I am surprised with how many patients who do not get along with me for these reasons stick with me and expect a different outcome next time.  I guess changing physicians must be more of a pain then getting what you think you want.

    Click to expand…

    Agree.  I think it is sometimes the “devil you know” strategy on their part.  Also, I think many patient’s families may seem unhappy with me but were unhappier with other docs they have seen.

     

    I’m curious: Does anyone have any experience with the corporate-type patient satisfaction training that nurses sometimes get?  Tricks like saying “I’m here to provide you very good care today” or “My goal is for this experience to exceed your expectations”.   I work with someone who is able to get patients saying he’s “the best” to translate into those same patients actually seeking out the form to put in a positive comment.  He comes from a nursing background.  (The care he gives is empathetic but not cost-effective or quality IMO.  So maybe that is part of it.)

    Anyone have a book or article rec for Jedi mind tricks to get patients to submit positive comments?

    #178330 Reply
    Avatar Tim 
    Participant
    Status: Accountant
    Posts: 3286
    Joined: 09/18/2018

    “Because if they truly understand what I understand then there would be no argument.”
    Bad assumption!

    Are we good? If it means that much, steer the favorable ones to the survey! Play the frigging game if you like reading compliments.

    #178340 Reply

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