How to say ‘no’ to a patient without compromising your relationship

A few years ago, a young female patient with an upper respiratory viral infection came to me requesting antibiotics. I explained that her infection was viral and should subside with fluids, rest, good nutrition, and OTC medicine. 

Giving in to patient requests

She told me that she would go elsewhere if I did not write her a prescription. I sent her on her way and told her that if her symptoms worsened over the next few days or she developed a fever, I would be more than happy to see her again. She ended up writing me a horrible review online, and this deeply hurt me. I had tried to do everything in my power to practice the best medicine possible and treat her with empathy and respect while practicing boundaries. 

I have lost count of the number of patients who come to me asking for opioid medications for non-severe pain, antibiotics for an apparent viral infection, diet pills for a quick weight loss strategy, expensive imaging tests that are not necessary, and so on. I hate to admit it, but sometimes I give in to these requests. 

I am not great at saying “no” to most people, let alone my patients, and often, this makes me a bad leader. It is easier to say “yes” than to say “no,” and when we are tired, burned out, and want to go home, sometimes we slip and give our patients what they want for the sake of not having to argue with them — and to avoid poor reviews. 

Putting patient satisfaction at risk

According to a study in JAMA, patient satisfaction is directly linked to their requests being fulfilled by physicians. When these requests are not fulfilled, physicians risk bad patient ratings and lower compensation.^[]

“For visits wherein patients' requests for these services were denied, patient satisfaction ratings were 10 to 20 percentiles lower when compared with visits wherein requests for these services were fulfilled,” the study authors wrote.

Practice the 'indirect no'

In a patient-centered practice, we encourage our patients to make shared decisions with their physicians, meaning the best treatment plan is a collaborative effort. However, at the end of the day, you are still the expert, and your duty as a physician is to “do no harm.” 

As a result, you have to use your best clinical judgment, regardless of the patient’s desires, which sometimes means saying “no.” 

If a patient requests something you feel is unnecessary, we can say no indirectly. An indirect no with an explanation often does the trick and does not leave the patient feeling angry and unheard. Here are some examples of what you can say:

• “Okay, we can consider your request, but let me tell you what I think.”

• 'Well, this could be an option, but let me tell you what I think we should do instead…”

• “I am unsure if that is the best option now, and here is why…”

If you choose to use the word “no” directly, follow it up with an explanation that is clear and empathetic to the patient. 

Engage in an open discussion

When your patient makes a specific request that is not in the best interest of their care, it is essential to do a deep dive to understand their reasoning. Patients with specific requests most often have a reason for it.

Maybe they read something on the internet, or their friend or family member used the same medication and it worked for them; maybe they are terrified their condition will become worse, and they want a full-court press right off the bat; or perhaps another doctor inappropriately prescribed medication for someone else with the same condition, and now they want to try it. 

It's important to peel back the layers of your patients' requests and then have an open discussion on your thoughts and reasonings. This is the best way to ensure patient satisfaction. 

Practicing the art of medicine

The “art of medicine” is often in how we communicate with patients.

We want our patients to feel heard and understand our reasoning, which often comes with lots of practice in communication. If our patients feel that we have genuinely listened to them, heard them, and addressed their underlying concerns, they most often will agree with our advice and leave our office satisfied.