Getting to No: How to Respond to Inappropriate Patient Requests
The five-step “FAVER” approach can help you say no to uncomfortable requests while preserving the patient relationship.
Fam Pract Manag. 2018 Jan-Feb;25(1):25-30.
Author disclosures: no relevant financial affiliations disclosed.
“Hey, doc, can you do me a favor?” This common question can quickly become one of the most challenging parts of your workday. Patients routinely ask for things that physicians feel are inappropriate.1 Requests for opioids or benzodiazepines, work or school excuses, expensive tests or procedures, family and medical leave certification, and durable medical equipment are each wholly appropriate under the right conditions. But what do you do when the conditions don't support the request? Uncomfortable feelings and avoidance are common responses. Physicians may even find themselves saying yes and later regretting it. Others may say no but do so in a tentative or equivocal manner that undermines the patient's confidence in the physician, prolongs the visit, and leaves both parties feeling dissatisfied.2
Learning how to say no to patients in an effective, professional manner that promotes good patient care and preserves the relationship, while supporting physician well-being, is a required skill. In our experience, few physicians have this skill naturally. Without a framework for responding to inappropriate patient requests, they may have a tough time getting to no.
We have developed an approach for handling inappropriate patient requests that is simple, standardized, and easy to adopt. The FAVER approach, spelled incorrectly for our purposes, includes five steps to minimizing patient and physician conflict and maximizing quality and rapport. (For a one-page summary of the model, see “The FAVER approach: responding to inappropriate patient requests.”)
Responding to inappropriate patient requests for opioids, work excuses, expensive tests, etc., is a skill all physicians need to acquire.
The FAVER approach begins with recognizing when you feel uncomfortable, because such feelings often signal that a patient request is inappropriate.
Assuming that the patient knows that his or her request is “wrong” will only complicate the interaction, so assume good intent.
When you have to say no, explicitly state why the request is inappropriate — e.g., it would be poor medical care, illegal, dishonest, or against policy — but avoid lengthy explanations.
F: RECOGNIZE UNCOMFORTABLE FEELINGS
FAVER starts with recognizing any uncomfortable feelings that stem from the patient's request. People are often adept at avoiding negative emotions, and physicians are no exception. In fact, they may have the added complication of being well-practiced at denying their own experience in service of others. Recognizing and not avoiding the discomfort of an inappropriate patient request is essential; it is the cue that you need to take
1. Kravitz RL, Bell RA, Azari R, Krupat E, Kelly-Reif S, Thom D. Request fulfillment in office practice: antecedents and relationship to outcomes. Med Care. 2002;40(1):38–51.
2. 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.
3. Parry S, Elliott C. Inappropriate requests from patients. CME. 2003;21(1):26–30.
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