When it’s hard to say no: tips on declining inappropriate treatment requests

If you find it hard to say no to patients, you are not alone.

A recent survey of Avant members identified this as a challenge across all specialities.

It may always be hard to decline a patient’s request, particularly when you genuinely want to help. However, there are ways of making it easier, in a way that you can maintain a good therapeutic relationship.

You are expected to use your clinical judgement and only provide care that is clinically indicated and likely to benefit the patient. Always agreeing to a patient’s request, especially where you disagree with it, may reduce patient dissatisfaction, but doing so may not fulfill your ethical and professional obligations. You should give patients what they need, not necessarily what they want. This may mean declining to prescribe drugs of dependence, or antibiotics, or refusing to refer a patient for tests you don’t believe are clinically indicated.

Key tips for saying ‘no’

Saying ‘no’ effectively while maintaining a therapeutic relationship can be done. You may wish to consider the following suggestions:

1. Listen to the patient
   
   Ask the patient about their symptoms and the reason for the request. Even if you ultimately decline to prescribe a particular medication or offer a test, you need to find out what else is going on.
   
   You and the patient may be able to agree on another approach or course of treatment, for example therapy or alternative analgesia options.
   
   Research suggests where patients feel heard and respected, even when they do not receive the treatment they requested, they generally report greater satisfaction with the consultation and may be less likely to complain¹.
   
   This accords with Avant’s analysis of claims data. In our experience, complaints where the primary issue was patients not having their requests or preferences met, often involved a secondary allegation of disrespect².


2. Consider carefully and explain your reasons
   
   Make sure you have not jumped to conclusions about the reasons motivating the patient’s request. Wait until you have asked the necessary questions and have received the patient’s response before you reach a decision regarding the patient’s request.
   
   Having heard the patient’s perspective and concerns, if you still believe the treatment is inappropriate, be willing to give a firm ‘no’ so there is no misunderstanding. Again, do so respectfully.
   
   Offer an explanation. Make sure to use everyday language and avoid medical jargon. It can be helpful to say why you are concerned, for example if you believe the procedure is too risky, or otherwise explain why you consider that the treatment is not in the patient’s best interests.


3. Keep it professional and stand your ground
   
   Try to remain calm and professional in your dealings with the patient. Be aware of your own mental state and how that is affecting your reactions. It can be more difficult to respond well to a challenging situation if you are tired, hungry or stressed.
   
   Make sure you understand any legislative restrictions, for example those associated with prescribing drugs of dependence. Keeping your own knowledge up to date will also help give you confidence in your decision.
   
   Maintain professional boundaries. Saying no is often even more difficult if your professional objectivity is compromised, which is why doctors are expected to avoid providing care to anyone with whom they have a close personal relationship.


4. Support your team and manage psychosocial risks
   
   Doctors sometimes tell us they have put their foot down with a patient, only to find themselves unsupported by colleagues or practice policies.
   
   From a practice perspective, it is important to consider the psychosocial risks these scenarios can present to doctors and staff and any changes needed to help manage them.
   
   Of course, it is important to consider each patient’s situation individually. However, if your practice has consistent policies and communicates these clearly, it will be easier to manage patient expectations early and reduce the risk of confrontations. The practice should also consider how to manage any potential issues if patients become upset. Options might involve training, managing appointment bookings or considering the layout for the practice waiting room.


5. Document carefully
   
   Carefully document the conversation in the patient's medical record, including the reason for declining treatment and any alternatives you discussed.
   
   Patients who do not receive the treatment they were hoping for may ask for a second opinion, or they may complain. Detailed records will help if your decision is reviewed by someone else after a patient complains.

References and further reading

1. Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “No”: Strategies Primary Care Physicians Use to Deny Patient Requests. Arch Intern Med. 2010;170(4):381–388. doi:10.1001/archinternmed.2009.533


2. Avant claims insights. Disrespect toward patients: Insights to reduce risk


3. Royal Australian College of General Practitioners. Position statement: Responding to patient requests for tests not considered clinically appropriate


4. Breivold J, Ro KI, Hjorleifsson S. Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study. Family Practice. 2022;125-129. doi:10.1093/fampra/cmab072



IMPORTANT: This article is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on its content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this article must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2023