How do you manage a patient’s insistence on an unnecessary test or drug? Is patient satisfaction a factor?
I recently attended a lecture on opioids-not something I would normally attend as I don’t prescribe opioids, but continuing medical education (CME) credits on the topic are now a requirement for maintaining a license in my state.
Although, I don’t prescribe opioids, I was struck by something the speaker said. Part of the reason prescription opioid abuse is so prevalent is that physicians feel compelled to overprescribe opioid pain medications because it gets them better patient satisfaction scores. Or conversely, if they do not prescribe “enough” opioids, they get bad patient satisfaction scores. In some practices, physician compensation is tied to such ratings. Some physicians are concerned about the impact bad ratings will have on the number of patients calling for new appointments. After all, who wants to see a doctor with 2 stars on Healthgrades?
In endocrinology, we generally aren’t asked for pain medications. If I am, I turf that back to the patient’s primary care provider or suggest seeing a pain management specialist. But I am asked for prescriptions for medications I don’t believe are appropriate for my patients. I’ve had men with normal testosterone levels ask for testosterone. I’ve had patients ask me for bioidentical hormones, which are not recommended by the Endocrine Society (this is for a whole separate discussion I do not want to have in this forum. I am just using this as another example). I have patients ask for weight loss medications, which I will use in the appropriate patients, but they aren’t for everybody.
We are also asked for tests that are unnecessary. I had a patient ask me to check her leptin level. I told her that a) it would not be clinically useful as there is no medication at the moment for either leptin deficiency or leptin resistance, and that b) it probably wouldn’t be covered by insurance, and I wasn’t going to spend my time or that of my staff getting it approved.
Often, a simple explanation is enough to dissuade someone from insisting on a drug or a test. But there are many patients who read something on the Internet or in some celebrity’s book that says this is what they need. Or worse, a non-physician (such as a nutritionist, a physical trainer, or even <horrors> their hairdresser) has told them this is what they need. Sometimes, it’s even another physician who suggests they ask me for something and yet are unwilling to order it themselves.
I tell patients that they don’t have to agree with me and that they have the right to seek another opinion. I have had patients leave the office upset that I will not prescribe what they want or request the test they want. I am sure any unhappy ratings I may have are from such patients. Am I willing to make compromises? Sure. But I cannot change how I practice medicine for the sake an extra star or a like or a thumbs up. Unnecessary tests are a waste of healthcare dollars. Although different from the opioid addiction crisis, we will be in a healthcare budget crisis if we allow the pursuit of high satisfaction ratings dictate how we practice.