CHAPTER 3
Perfect Phrases for Patients Wanting Medically Unnecessary Prescriptions or Tests

Patients may approach medical care with strong expectations that they will be prescribed certain types of testing or treatments. These expectations arise from a variety of sources. One compelling source is having seen family or friends undergo treatment for similar medical conditions. Another is the depiction of modern medicine on television and film. These media depictions, although often unrealistic, can be powerful to people without medical training. In addition, there is a preponderance of direct marketing of medications, medical devices, and services to consumers. No one can open a magazine, turn on the television, or browse the Internet without running into an advertisement for a new drug or a local hospital’s gastric bypass surgery suite.

As a result of these influences, patients often ask for certain medications by name or request that certain testing be performed (e.g., magnetic resonance imaging [MRI] for knee pain or invasive cardiac testing for chest pain). On the one hand, it is important for patients to take an active part in their medical care by engaging their healthcare providers. By questioning the rationale for medical decisions, patients become more informed and therefore more invested in their own care. On the other hand, patients are not always aware of the risks, benefits, side effects, and costs of the care they are requesting. It is our job as healthcare professionals to educate patients about what we think is the best way to diagnose and treat their ailments. That may mean that we recommend simpler diagnostic testing before moving on to more invasive and expensive testing or a generic medication instead of the latest name brand pill.

When we make these recommendations, patients may imagine that we do not have their best interests at heart because we aren’t satisfying their preconceived expectations of treatment. As healthcare professionals, we need to be able to effectively communicate to patients why we are making the recommendations while still maintaining a strong and trusting relationship with patients and their families.

Perfect Phrases for Patients Requesting Unnecessary or Inappropriate Medications

Mrs. Johnson is at her doctor’s office and is requesting a new medicine for blood pressure that she saw advertised on television. She thinks that the new medicine will work better than her current ones. You (as her doctor, nurse practitioner, or physician’s assistant) don’t feel, on the basis of current studies, that the new drug works better, even though it costs five times as much as her current medications.

→ I think it’s great that you are paying close attention to your high blood pressure. I also want to make sure that your blood pressure is well controlled.

This patient is clearly invested in her care and is engaging her healthcare provider to ensure that she gets the best care possible. Not all patients pay attention to their chronic diseases, so this patient should be appreciated and encouraged to continue managing her disease.

→ I, too, have seen the advertisements for this new medicine, but at this point I don’t think the new medicine has proven to be more effective than our current options. Here are the adjustments to your current medications that we can try to better control your blood pressure.

Direct-to-consumer advertising (DTCA) can play a powerful role in which medications patients request. According to the Nielsen Company, in 2008, pharmaceutical companies spent more than $4.3 billion in the United States alone on DTCA for prescription drugs. The only industry spending more on DTCA was the automobile industry. As healthcare professionals, we should recognize the influence that DTCA can have on patient requests. If an expensive, brand name medication is not medically necessary, explain this situation clearly to the patient and encourage him or her to try a less expensive generic medicine.

Elizabeth is a 20-year-old college student who has visited a psychiatrist’s office for help with her mood swings and fatigue. After interviewing the patient, the psychiatrist thinks she may have bipolar disorder and suggests a mood stabilizing medication. The patient reacts angrily to this suggestion.

→ I don’t know what you are talking about—I need you to write me a prescription for Zoloft because I have generalized anxiety disorder.

This patient clearly feels that she has a specific disorder. Ask explicit questions to find out why the patient feels that way and what she wants or expects of you as her healthcare provider.

→ Why do you think you have generalized anxiety disorder? How did you hear about Zoloft?

→ I saw an ad in a magazine I read.

→ What about this ad hit home for you?

→ Well, the ad mentioned symptoms such as fatigue, anxiousness, mood swings, and irritability. I feel like I have all those symptoms, so I must have generalized anxiety disorder. Why don’t you think I should get Zoloft?

In this patient’s case, the patient has strongly identified her somatic and psychiatric symptoms with the advertising for the name brand medication. Acknowledge the patient’s concerns and her perception of her problem.

→ I see where you are coming from, and I’m glad that you have come in to my office to get some help. I agree with you that your symptoms may be due to a psychiatric condition. I’m just not sure that the condition is actually generalized anxiety disorder. I would like to check a few blood tests and try you on another medication first. If it does not work for you, I will be happy to revisit this issue.

Mr. Sanchez is at his surgeon’s office and is being seen in follow-up for a minor leg surgery. While there, he asks the surgeon for a prescription for refills for his hypertension and diabetes medications.

→ The incision on your leg is healing well. As for these medications, I think it would be better if you saw your family doctor to get prescriptions if they aren’t related to your surgery.

→ Come on, doc. Can’t you just write me a prescription for these medications? I have to make another appointment with my family doctor, and I’m already here. You are a doctor. All you have to do is pick up a pen.

In this case, the patient is requesting medications that are medically necessary for his medical problems. But it is not appropriate for the surgeon to refill these medications. The patient’s primary care provider should be coordinating all of his care. Specialists or consultants may choose to prescribe medications related to the condition they are treating, but refills or adjustments to other medications should be left to the physician who originally wrote the prescription.

→ It would be better for you to see your primary care doctor to get these medications. Your family doctor may want to adjust your medications or do some routine blood testing to check up on your diabetes. I’m sorry that you will have to take time out of your schedule for another appointment, but I think it’s better for you in the long run.

Mr. Shah has made a sick visit appointment at his family doctor’s office. He has had three to four days of muscle aches, fatigue, and rhinorrhea. The physician assistant who is evaluating him has diagnosed him with a viral upper respiratory infection (URI).

→ I think I need some antibiotics. The last time I had something like this I took some pills, and it went right away.

It is a common misconception that a URI should be treated with antibiotics. Educating our patients about this medical myth and others is an important part of our role as healthcare professionals.

→ I think that what you have is a cold—we know that viruses cause almost all colds. Antibiotics don’t work on viruses. They only work on bacterial infections, so I don’t think a prescription for antibiotics will help you get better.

→ But I’m tired of feeling sick. I really think some antibiotics will help.

→ I’m sure you are sick of feeling achy and having a stuffy head. But again, antibiotics are not likely to help your situation. I think you will start to feel better in a few days regardless of whether or not I prescribe you antibiotics. There are also some potential downsides to antibiotics, such as stomach upset and diarrhea. I suggest we treat you with some pain medications, decongestants, and a few days of rest.

A reasonable explanation using simple words regarding why you don’t recommend antibiotics can dissuade some patients from requesting unnecessary prescriptions. Yet, other patients may be insistent that you write them prescriptions for antibiotics. As healthcare professionals, we are never obligated to write a prescription if we don’t think the patient needs it or if it may harm the patient.

Nevertheless, you have to pick and choose your battles. Convincing a patient to forgo an unnecessary prescription may take an inordinate amount of your time or may jeopardize your relationship with the patient. If the patient is absolutely insistent on a prescription for a short course of antibiotics, which has a low risk of any serious side effects, it is within your discretion to relent. It is our job to make sure that our patients are informed about the risks and benefits of medical interventions. Patients do have the right to make decisions about their own care, even if the decisions are unwise.

→ A decongestant and rest aren’t going to work. I really NEED some antibiotics.

→ OK. I can write you a prescription for a short course of pills. I want to emphasize that I don’t think this is the best thing for you. But you have been our patient here at the clinic for a long time, and we want you to be happy and healthy.

Mr. Lange has brought Leela, his 5-year-old daughter, to the pediatrician’s office for a sick visit. The girl has had three days of runny nose and intermittent low-grade fever. The pediatrician has examined the patient and feels that she has a viral URI.

→ I think Leela needs some antibiotics. I want her to get over this illness soon.

This parent is simply doing what he thinks is best for his child and he may argue vociferously for a specific treatment if he feels that she needs it. Again, antibiotics are of no use for a viral URI. But in this case, the practitioner needs to address two “patients”—the parent and the child. Educate both the parent and the child about the proper use of antibiotics.

→ We want Leela to get better soon as well. But after examining her closely, I find that there aren’t any signs of a bacterial infection. I really think her symptoms are due to a viral infection, and these usually get better on their own in two to three days. I think antibiotics would just give her an upset tummy and diarrhea but do nothing for her cold. Instead, let us advise you about how to treat her symptoms. We will also see her back in the office at any time if she gets worse.

Perfect Phrases for Patients Requesting Medications with the Potential for Abuse

Mrs. Gordon is a 39-year-old woman with bipolar disorder and chronic back pain. She has recently started visiting your primary care office and has made requests for large amounts of narcotic pain medications at each office visit.

Healthcare providers can be placed in a quandary when patients ask for medications with the potential for abuse. It is our duty to help relieve pain in our patients, but we must do it in a safe and responsible way. Narcotics and benzodiazepines, two of the most commonly abused classes of medications, are powerful and can help relieve pain, but their misuse can lead to serious consequences, including death and disability.

Determining which patients have a genuine need for medications and which patients are “drug seekers” can be very challenging. Patients won’t admit outright to “drug seeking” because they may be ashamed of their addiction or afraid that we won’t write them prescriptions for the medications they desire. Nor are there any tests that can help us identify the patients who want medications for illicit use.

Some red flags for possible “drug-seeking” behavior are a prior history of drug or alcohol abuse, repeated requests for medication for the same complaint, multiple drug allergies, and requests for specific medications by name or milligram dose. But again, these red flags are not absolute indicators. Therefore, we have to rely on our clinical impression of the patient to determine whether they have a true medical need for a medication.

Bringing up the possibility of medication abuse with the patient in the above vignette can be awkward and difficult. The Substance Abuse and Mental Health Services Administration advocates some general principles that may make this conversation easier.

Assure the patient that your motivation for the discussion is his or her overall health.

→ I know this may be difficult to talk about, but I need to bring up your use of narcotic medications because I am concerned about your health.

Don’t assume a judgmental or accusatory attitude, and assure the patient that you will maintain confidentiality.

→ I’m not here to judge you, and the things we discuss will be kept confidential. I just want to make sure we do what is best for your health.

It is impossible to know exactly what our patients are going through, so try to empathize with them, whatever their situation may be.

→ I’ve taken care of many patients with similar issues. I’ve seen firsthand how tough it can be.

Asking “open-ended” rather than “closed” questions can help avoid a pointed or confrontational interaction.

→ [Closed] How long have you been abusing drugs?

→ [Open] Do you think you have had some issues with drugs?

→ [Closed] Why are you using so many pills?

→ [Open] I’ve just told you about some of my concerns about your use of prescriptions. What do you think about what I’ve said?

→ [Closed] Why should I keep writing you all these narcotic prescriptions?

→ [Open] Are you concerned about your use of prescriptions?

It is impossible to know ahead of time exactly how a conversation about potential medication abuse will play out. Some patients may be open to a discussion and request help in dealing with their abuse issues, whereas others may become infuriated that you have even raised the subject. Keep these principles in mind, and don’t judge your patients before you hear what they have to say.

→ I do need to discuss something with you today. You have requested some very large doses of very strong narcotic pain medications. I know you have some issues with your back, but I’m concerned about your use of these medications and their effect on your health. Some patients, through no fault of their own, can get a little too reliant on these medications. Do you think you may have become dependent on narcotics?

→ I don’t have any problems with pills. I need the oxycodone for my back. I’m allergic to ibuprofen, and acetaminophen just doesn’t cut it.

How far you want to go in discussing potential medication abuse with your patients is at your discretion. Nevertheless, if patients deny abusing medications but you still aren’t comfortable giving them prescriptions, let them know why.

→ I appreciate your assurances about your use of these medications. Nevertheless, I’m not comfortable writing you a prescription for so many pills at one time. These are extremely powerful medications, and they can have serious and life-threatening side effects. I can write you a prescription for some non-narcotic pills. If that isn’t satisfactory for you, I think it may be best if we refer you to a pain clinic—they may be able to do more for you.

Perfect Phrases for Parents Requesting Tests for Minors: Ethical Issues

Jean is a 16-year-old girl who is at her pediatrician’s office for a checkup. Jean’s mother pulls the pediatrician aside outside of the exam room and asks for her daughter to be tested for pregnancy and drugs.

→ Jean has been acting funny lately. She also has been spending a lot of time with a boy from school. I’m worried she could be pregnant or doing drugs or drinking. Can you just do some tests to find out if she’s pregnant or using drugs?

The mother, as the guardian of this minor, can consent for tests on her daughter. Doing tests for pregnancy or drugs without the patient’s knowledge, even if that patient is a minor, can raise some tough ethical and trust issues. Whether or not you, as a healthcare professional, order these tests depends on your own values and your relationship with the patient and the parent.

→ I don’t think it’s a good idea to do tests on your daughter without her knowledge. These tests aren’t 100% accurate, either, so we won’t be completely sure that your child is or isn’t using drugs on the basis of one urine test or blood test.

If you don’t feel it is a good idea to order the tests, make sure to offer alternatives to deal with the issues that the parent has raised.

→ Could we try something else to deal with your concerns? Would you like me to discuss the risks of drug abuse and teen pregnancy with your daughter? I can also give you a pamphlet with some recommendations on how you can bring up these issues with your daughter yourself.

If you do choose to perform the requested tests, make sure that you discuss ahead of time the accuracy of the test and what the parent will do with the results.

Perfect Phrases for Patients Requesting Specific Treatments

Mr. O’Malley is a 56-year-old man with hypertension, who has come to his primary care doctor’s office. He has had two weeks of low back pain that seems to be gradually improving with physical therapy.

→ This back pain seems to be getting a little better but it’s still bothering me. I really think I need an MRI (magnetic resonance imaging) of my body.

Patients may want a certain test or medication for a specific reason. A friend or relative might have been diagnosed with a medical problem, and now they may be worried that they are suffering from the same condition as well. There may be no medical indication to order the test, but don’t demean your patients or their reasoning behind the request for the test. Rather, try to find out why they want the test, and educate them about the options to address their concerns. Some patients may only be seeking reassurance about their symptoms, and discussing their symptoms can ease their concerns.

→ For back pain, we would limit the MRI to your lower back area. Is there any specific reason you want one? Are you worried about something in particular?

→ I saw on TV that someone who had a slipped disc found out about it only after an MRI. What if I have the same problem?

It is appropriate to make patients aware of the costs of the medications or tests they are requesting. The Centers for Medicare and Medicaid Services estimates that almost 18% of the U.S. gross domestic product (GDP) was spent on healthcare in 2009. Any test, expensive or not, should be ordered only if a patient needs it.

→ An MRI can tell us about the discs in your back. But it is a very expensive test, and I’m not sure it would change what we are doing at present. You do seem to be improving with our current treatment plan. Let’s stick with it. If your progress stalls or your condition worsens, I can order an MRI for you.

Mr. Massone is a 36-year-old man who is at a gastroenterologist’s office for the first time to be evaluated for dyspepsia. The physician has examined him and is finishing up the encounter.

→ I think we should send you for testing for a stomach bacterium called Helicobacter pylori. We should also start you on a medicine called a proton-pump inhibitor, which should alleviate your symptoms.

→ Umm, all right. Fine.

If the patient’s body language expresses discontent or the tone of voice indicates disagreement with your plan, don’t ignore that cue. Rather, address this dissatisfaction right away. We must manage the expectations of our patients early in the development of our relationship with them.

→ You don’t seem too happy with this plan. Is there anything you think we should be doing differently? What is the best way for me to help you today?

→ Well, I came here because I thought I was going get a scope of my stomach. I can just go buy this medicine over the counter without even seeing you.

→ I’ll be happy to perform an examination of your stomach with a scope—that procedure is called an EGD (esophagogastroduodenoscopy). But there are risks and costs associated with putting a camera into your stomach. I do think it’s a good idea to rule out the common causes of a stomach upset before performing an invasive procedure such as an EGD. If the tests for H. pylori don’t show anything and you get no relief from this medication, we will get you in for an EGD right away.

Mr. Larson is a 27-year-old man who is at the Emergency Department (ED) with a sore throat. The physician assistant is evaluating him.

→ I have strep throat. I’ve had it a bunch of times. I just need to get my tonsils out today. Can you get me a throat surgeon?

Patients can present to an outpatient office or an ED with expectations that medical problems can be fixed immediately. The patients may be fed up with their symptoms and can have unrealistic expectations. Let the patients know that you sympathize with their problems but that non-emergent medical conditions aren’t operated on or addressed on an emergent basis. Make sure to end the encounter by providing the patient with some options for what can be done, not merely what cannot be done.

→ I’m sorry that you are experiencing a sore throat again. Unfortunately, we don’t arrange for tonsillectomies through the ED. What I can do is examine you and prescribe antibiotics and pain medications if you need them. After that, I can refer you to a throat surgeon if you are still having problems.