Does Physician Denial Of Patient Requests Result In Decreased Patient Satisfaction?

The short answer: No.
 
At least not in the context of a strong physician-patient relationship.
 
Many physicians have legitimate concerns about the prospects of having their salary or level reimbursement linked to patient satisfaction. I would too given the way most health care providers go about measuring and interpreting patient satisfaction data.
 
A major concern of physicians is the issue of patient requests – particularly the impact of unfulfilled (and unreasonable) requests upon patient satisfaction. According to researchers, explicit patient requests for medications, diagnostic tests and specialty referrals occur in between 25% to 40% of primary care visits. This figure is much higher when requests for information are factored in.
 
In studies, primary care physicians accommodate patient requests for medications and diagnostic tests approximately 75% of the time. Physicians however accommodated only 40% of specialist referral requests. Physicians negotiated alternatives solutions to patient requests 22% of the time and denied patient requests the remaining 3% of the time. Information requests were met approximately 95% of the time by physicians.
 
Denial Of Patient Requests Has Little Impact On Patient Satisfaction
 
It is not at all clear from the research that physician denial of patient requests for medications, tests or specialist referrals has any negative effect on patient satisfaction. In the studies referenced here, little to no association was found between unfulfilled patient requests and patient satisfaction.
 
The one exception to this finding is where physicians fail to meet patient requests for health information. In such instances patient satisfaction was lower. This is not surprising when one study categorized the quality of physician responses to patient information requests as follows:
 

• 32% were of requests were fulfilled with a “terse” physician response
• 33% percent were fulfilled with an “intermediate” response
• 32% percent with an “elaborate” response.

 
Experts Advise Negotiating Patients Requests
 
It has been said that clinical encounters such as occur during office visits involve a “process of negotiation between the clinician and patient.” As such, physicians are advised to use the influence accorded them by their patients to help them understand the pros and cons of their request so as to negotiate actions are really needed.
 
Physicians that are truly concerned about their patient satisfaction score are better served by looking after the quality of their patient communications skills.
 
Sources:

Kravitz RL, Bell R a, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Services Research. 2002;37(1):217-38.

Kravitz RL, Bell R a, Azari R, et al. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Archives of Internal Medicine. 2003;163(14):1673-81.

Peck BM, Asch DA, Goold SD, et al. Measuring Patient Expectations – Does the Instrument Affect Satisfaction or Expectations? Medical Care, Vol. 39, No. 1 pp. 100-108.

Keitz S a, Stechuchak KM, Grambow SC, Koropchak CM, Tulsky J. Behind closed doors: management of patient expectations in primary care practices. Archives of Internal Medicine. 2007;167(5):445-52.

Rx Non-Compliance and Ineffective Physician-Patient Communication – Two Sides Of The Same Coin

Lots of smart people over the years have been trying to figure out why people stop taking their medications within the first 12 months.  Within the first 12-months of starting a new prescription, patient compliance rates drop to less than 50%.  This rate is even lower for people with multiple chronic conditions taking one or more prescription medications.
 
If these medications are so important to patients, why do they just stop taking them? It defies common sense. Sure issues like medication cost, forgetfulness, lack of symptoms, and psychosocial issues like depression play a role in patient non-compliance. But there also something else going on…or in this case not going on.
 
The problem is that doctors and patients simply don’t talk much about new medications once prescribed. Here’s what I mean.  Let’s say that at a routine check-up a physician tells a patient that he/she wants to put them on a medication to help them control their cholesterol.  The doctor spends about 50 seconds telling the patient about the medication.  The patient nods their head takes the prescription and boom…the visit is over.
 
Let’s say the patient actually gets the prescription filled.  For some people that is a leap of faith considering the likely chain of events up to that moment:

 
• The physician didn’t really make a good case for why they needed the medication (if the doctor wanted me to take it he/she should have been emphatic about it as in “I recommend you take this” – not simple “I want to try something”), what it would do or what would happen if the patient didn’t take it.
• The doctor didn’t mention how the new medication would interact with the 2 other pills I am already taking.
• Consequentially the patient may not believe they really need the medication.

 
Fast forward 12 months. The patient has been back to see the same doctor twice for problem unrelated to cholesterol. At neither of these appointments did the doctor mentioned or ask how the patient was doing with the new medication. The doctor did mention the need for a blood test to check for liver issues and that they should recheck the cholesterol levels at the next visit.
 
So at this point the patient concludes the following about the new medication:

 
• The doctor never talks about cholesterol or brings up the subject of the medication. I assume I am taking it correctly.
• If the doctor doesn’t mention it (the medication) it must not be important.
• I haven’t notice any difference in my health – I guess I don’t need the medication.

 
Sure the patient should have asked their doctor if they had any questions about the new medication. But patients seldom ask their doctor questions. Sure they could ask the pharmacist…but the pharmacist would tell them to just ask their doctor.
 
It so much easier for the patient to just not refill the prescription.
 
We have all heard the expression that whatever doesn’t get measured doesn’t get done.  Well the same thing is true for when it comes to physician-patient communications.  Whatever issues doctors don’t talk with patients about will not get done over the long haul either.  In this case patient’s simply stop taking prescribed medications.
 
As primary care slowly shifts from episodic, acute care to continuous care with the aid of EMRs and the focus of patient-centered care things should get better with respect to patient compliance. It needs to. Give the current focus on episodic acute care too many chronic health issues simply are not being addressed for one visit to the next.
 
That’s what I think. What’s your opinion?