Doctors and inappropriate patient requests (such as for drugs or jury duty excuse)

When they say "doctors have seen and heard it all," that applies in a number of ways.

And sometimes not in good ways.

Sometimes there are patients who make requests of their doctors that are not only inappropriate, such as for legal but unnecessary drugs, but sometimes even for them to take illegal actions, and for some reason that doesn't stop them from making them.

The article below, from the journal Family Practice Management, 2018;25(1):25-30, addresses this topic, and gives some examples of these inappropriate requests:

"Requests for opioids or benzodiazepines, work or school excuses, expensive tests or procedures, family and medical leave certification, and durable medical equipment."

and adds:

"But what do you (the doctor) 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 ... 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."

The article then proposes an acronym, FAVER, as a tool for remembering steps useful to take in handling these situations:

F - Feelings

Name your feelings about the patient's request — anger, fear, sadness, annoyance, etc.

A - Analyze

Analyze your thoughts about the request and what is fueling your feelings. Would fulfilling this request be poor medical care or Illegal, dishonest, or against policy?

V - View

View the patient in the best possible light. Don't assume the patient knows that what he or she is requesting is “wrong.”

E - Explicit

Explicitly state that the requested action would be poor medical care, or illegal, dishonest, or against policy.

R - Reestablish

Reestablish rapport. Use empathy and “I wish … ” statements.`

Especially interesting are some of the standard replies doctors can use in these situations, offered for use when answering inappropriate requests:

“It would be poor care for me to prescribe that medicine. You do not come to see me for poor care. You come to see me for my best medical judgment.”

“It would be poor care for me to do X. Good care would be Y.”

“I understand that Dr. X has given that to you in the past. Doctors do not always agree. You come to see me for my best medical opinion, and I believe it would not be good care for you to take X.”

“I understand why you want to avoid jury duty. I wish I could help you, but it would be illegal for me to state things (in a written medical excuse to the court) that are not true.”

"We could both end up in jail if we do X.”

“I am sorry you were not aware of those rules. We still have to follow them.”

There are even a few words on how to handle the situation if the patient becomes combative or threatening, if the doctor does not agree to his inappropriate request(s).

And there are likely situations urologists have seen in their practices, where a patient with a prostate issue has made a request that the uro feels is entirely unreasonable, but must now convince the patient of that, while keeping the situation from becoming confrontational.

Maybe sometimes we neglect to consider that there are some patients who do behave in these ways, and they can become a real challenge for a doctor to deal with.

When that is the case, methods for dealing with it such as the above can be just another tool in the doctor's medical bag, although probably one he would most likely rather not have to use.

https://www.aafp.org/pubs/fpm/issues/2018/0100/p25.html

I can only imagine how difficult it must be for a medical doctor to deal with all the different patient personalities he or she sees in a realm of a ordinary practice. Particularly people who suffer moderate to severe illness and aren't hitting on all cylinders. I sure hope there's some serious training in medical school related to the human interaction aspect of being a physician in a medical practice. I wonder how a doctor would react if a patient asked him or her to do something unethical or illegal? I guess it would all depend upon who it was coming from and under what circumstances. But trust is a two-way street. Even if I had the smarts and the drive to make it through medical school, don't think I'd want to wear that white coat. Tough gig. But I certainly respect those who do. They earn decent coin, but most more than earn it. Most of the ones I've talked to wouldn't recommend their children to follow in their footsteps.

Swan, interesting point about hospice care.

When my father was dying with advanced prostate cancer (it got into his spine), the hospice nurse was very clear in her opinion about how it worked. They had a whole series of pain meds, each stronger than the previous one. Her opinion went like this: The last one we give is morphine. Most likely, when the last one doesn't work, we'll give him a small dose of morphine, and he will sleep for 12 hours or more, and be gone within 24.

Her theory is that the pain relief is so significant that the patient is able to relax and stop fighting.

And that is what happened.