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

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[tweetmeme source="Healthmessaging" only_single=false]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.

2 Comments

  1. Joe Chiarella says:

    The requests are a teachable moment, and represent the opportunity to improve a lot more than patient satisfaction scores. Patients don’t generally ask for tests on a whim, they have some concern (generally similar to their brother-in-law’s friend’s cousin who had a diagnosis made by PET scan) but they don’t want to ‘bother you’ or don’t have enough information to back up their request.

    This is a time to go over what is behind the request. Are there symptoms, have things been going on in the patients life that you need to know about in order to properly manage your patient? If you use requests like this to dig into the real reason and actually have a positive impact, that would certainly improve your patient satisfaction score, it’ll just take an extra visit or two!

    • Joe,

      There’s a body of research that comes out of the sociology field which talks about the benefits of a physician using “online commentary” to help patients better understand the necessity/implications of their request. Take the PET scan and fear of lung cancer for example. As the physician is doing a history and physician on the patient, the “online commentary” addresses this by ruling out (or not) the presence of symptoms (cough, shortness of breath, and so on. ) As the theory goes, by ruling out the symptoms, the physician is giving the patients peace of mind in knowing they probably do not have anything to worry about. Of course everyone has a friend who cancer was misdiagnosed or totally missed in which case online commentary may not be enough.

      Thanks for pointing out the value of investigating the patients beliefs which motivated the request in the first place. Requests are indeed one of many such teachable moments which, along with other patient “clues” are often overlooked by busy providers.

      Steve Wilkins

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