“Thanks for nothing!” my patient said as he stormed out of my exam room. He was an otherwise healthy 22-year-old with a three-day history of sore throat, cough, and congestion, but no fever. He was eating and drinking well, and the review of systems was otherwise negative. His vital signs were within normal limits, with an unimpressive exam overall. Despite my low clinical suspicion for streptococcal pharyngitis, per our local protocol, I did offer to do a rapid strep test and throat culture.
“No, that makes me gag,” he said.
We went back and forth, and I did my best to appease him. When I refused to give him antibiotics for his self-diagnosed strep throat, offering a myriad of supportive medications instead, he left in a huff.
These occurrences are common in family medicine, whether they involve a patient demanding antibiotics or other drugs, or complaining about wait times or insurance rules. The root issue is a discrepancy between the patient's expectations and what we as physicians can reasonably do.
How do we reconcile these issues to minimize negative encounters?
1. Seek to understand the true goal of the patient. When we don't see eye to eye with a patient, our first step should be to try to understand his or her goal. It may be as simple as relief from the symptom bothering the patient the most (sore throat in the earlier example), or it may be connected to a deeper issue — a need for assurance, a desire to be heard, or worries about end-of-life comfort. Active listening and validation of concerns are key.
2. Protect continuity of care. This helps us build rapport and a trusting relationship with the patient over time. It also helps foster an understanding of the social background and underlying concerns, which may be difficult for the patient to articulate. We can then offer to discuss the issues and counsel the patient as indicated.
3. Remember that what is best for the patient may not be what the patient wants. Sometimes, in the best interest of the patient or the community (in terms of antibiotic and opioid stewardship, for example), we must make decisions that do not align with the patient's wishes. In these instances, we should communicate the factors that contributed to our decisions and must be comfortable standing our ground, even when challenged.
4. Accept the patient where he or she is. On top of feeling sick, the patient may feel confused, frustrated, scared, etc., and unable to express or control emotions in the moment. But we can control our responses. Knowing we are doing what is best for the patient, even if he or she can't see that yet, can help us maintain a sense of calm.
5. Document to protect ourselves. In encounters like the one described above, it's important to document the events, the discussion, and the medical decisions made. An unhappy patient is more likely to make complaints, so being preemptive about explaining why things were done or not done can help us avoid frustrations later.
6. Do not internalize negative comments. It's easy to take these comments personally. Those of us drawn to family medicine are altruistic and patient-centered. Negative patient comments can be unsettling. Our internal monologue might include questions such as, “Why doesn't the patient understand that I am trying to help?” We must be comfortable knowing that we did our best and we cannot, nor should we, please all.
7. Engage and empower the patient. Although we may not always be able to give the patient what he or she wants, we must engage the patient, not withdraw. Instead of simply saying “no” or “I disagree,” present options or alternative treatment plans. If a stalemate persists, recommending a second opinion can help demonstrate that we care and are willing to explore other opportunities.
Next time a patient exclaims, “Thanks for nothing!” we shouldn't blame ourselves or the patient. Instead, remember these seven tips to respond more effectively.