Physician Ratings Lowered When Patient Requests Denied

DECEMBER 07, 2017
Jenna Payesko
Anthony Jerant, MD, lead author, chair, Department of Family and Community Medicine, UC Davis HealthAnthony Jerant, MD
A new study shows that patients asking for specialist referrals, laboratory tests or certain medications and are denied these requests, tend to be less satisfied with doctors than those whose requests are fulfilled.

Study authors from UC Davis Health recommend communications training for physicians which will in turn foster positive experiences for patients without agreeing to all requests for particular diagnostics or treatments.

"We know from prior work with antibiotics that an approach doctors can use/offer called watchful waiting has some promise," Anthony Jerant, MD, professor and vice chair, department of family and community medicine, UC Davis School of Medicine, told MD Magazine. 

The cross-sectional study evaluated 1,141 adults making 1,319 office visits to 56 family physicians at a Northern California academic health center. The mean age of patients was 45.6 years old, and about 68.4% were females.

Over the course of approximately a year, patients answered survey questions about office visits with their doctors, including requests for medical services, assessments of the doctor’s communication and support, and overall doctor ratings.

Researchers used 6 Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey items to measure patient satisfaction with the physician. Standardized items were average to form the satisfaction score, which then was percentile-transformed.

There were 7 separate linear mixed-effects models that examined the adjusted mean differences in patient satisfaction percentiles associated with a possible denial of each request — referral, pain medication, antibiotic, other new medication, laboratory test, radiology test, or other test — compared to requests fulfilled.

The models adjusted for patient specifics i.e. sociodemographics, weight, health status, personality, worry over health, prior visits and the 6 other request categories.

Patients in the study made nearly 1,700 specific requests of their doctors. When fulfilled, approximately 85% of the time, satisfaction was generally high, however, when patient requests for referrals, pain medication, other new medication and laboratory tests were denied, clinician satisfaction ratings lowered by 10–20 percentage points.

Denial of specific request types were associated with worse patient satisfaction with the clinician, but not for others whose requests were fulfilled, which suggests the need for clinician training in request handling.

Requests by category were referral, 21.1%; pain medication, 20.5%; antibiotic, 8.1%; other new medication, 20.5%; laboratory test, 34%; radiology test, 11.6%; and other tests, 11.1%.

Among the patients’ 1,139 visits, 68% included at least 1 request, and 85.2% of the requests were fulfilled.

The differences were noteworthy since analyses accounted for a broad range of patient characteristics, which previous research suggests can influence satisfaction ratings.

When patient-satisfaction drives compensation, the findings recommend the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.

There are ways to handle patient requests in a way that maintains satisfaction, and engages and informs patients, no matter if the requests are filled or denied. It’s key to address the underlying concern that prompted the request.

It’s important to note that antibiotic prescription and imaging test referral were not associated with lower satisfaction. Through initiatives that reduce low-value care, substantial attention has been devoted to preparing physicians to avoid requested, low-value care like the aforementioned.

Researchers suggest physicians are trained to say no to other types of clinically inappropriate requests while ensuring patients’ needs are meet.

Jerant believes the watchful waiting strategy, a middle ground between a straight denial and immediate go ahead, could be useful to physicians. Here, physicians don’t start off with no, but negotiate with the patient — more of a wait and see approach.

“If some improvement point or resolution of the issue that triggered the patient request isn’t reached by the end of that time period, you regroup and reconsider and in some cases at that point the doctor might well acquiesce,” added Jerant.

At this point physicians have filtered out some of the low-value care by giving the patient a chance to calm down, so to speak.  

According to Jerant, patients may be less likely to react badly if they hear, “I don’t honestly feel that service X would be helpful to you and it could cause harm/problem Y. But I hear you are concerned. So how about if we see how things go over the next few days and then you can call me and let me know if you’re still of the mind that you’d like me to (fill in the blank)?”

This watchful waiting approach has great potential, Jerant noted. He, along with the other researchers, hope to study this in the future – training docs in how to use it – to see if they will use it, and if so, if their use of the technique reduces unnecessary care use without a reduction in their patient satisfaction scores.

“Physicians rarely receive training on how to deal with those situations, which is crucial given the importance placed on patient-satisfaction survey results in improving health care and, in some cases, to determine physician compensation,” added Jerant.

In future studies, the authors hope to evaluate whether training physicians to effectively manage patient requests could improve the situation.

The study, “Association of Clinician Denial of Patient Requests with Patient Satisfaction,” is made available in JAMA.

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