1. Google video The 'Angelina Jolie effect': Her mastectomy revelation doubled NHS breast cancer testing referrals

2. Handling Patient Demands MAJ/P Elizabeth Duque, MD, MBA USAFP 2015

3. Dilemma 1.Media, Celebrities, Internet 2.Doctor – patient relationships 3.Customer service focus 4.Culture of society 5.Limited time 6.Ethics

4. Conflicting ethical considerations Patient autonomy versus professional integrity Autonomy versus do no harm (risks and benefits) Cheating versus justice (stewardship)

5. Case Studies 1.A 28 year old female comes in requesting her “annual blood work”. 2.A patient comes in demanding a referral to neurology for headaches. She has never been evaluated or treated for them before. 3.A patient comes in requesting Vicodin for back pain? What if it were Celebrex?

6. Some data 24% of physicians view patient requests as positive 43% view them as having a negative impact on patient care and interactions More than 10% of patients will make a request for a specific medication 19.8% of patients will receive a narcotic if they request on 1% will receive a narcotic if not requested 53% will receive Celebrex if requested 24% will receive Celebrex if not requested 85% of ER providers ordered CXR if requested, even thought 0% thought it was clinically indicated

7. How do you respond?

8. Before Responding SELF AWARENESS Understand your own biases Challenge your initial assumptions

9. Before Responding Understand the Patient’s Request What is the context of the request What is the authenticity of the requests What is the underlying concern What assumptions/biases does the patient bring

10. Before Responding Know Your Bottom Line Set boundaries For what will you fall on your sword for? Patients cannot insist on treatment that is against your clinical judgment

11. Before Responding Consider Alternatives This is where prep work becomes important? Can you seek a consensus with the patient? Are there research opportunities or other sources for the patient to be involved in that would meet the patients needs?

12. Case Studies 1.A 28 year old female comes in requesting her “annual blood work”. 2.A patient comes in demanding a referral to neurology for headaches. She has never been evaluated or treated for them before. 3.A patient comes in requesting Vicodin for back pain? What if it were Celebrex?

13. Responding

14. Summary Patient demands are common and can challenge providers There is no set way in which to respond Appeal to authorities (organizations, guidelines, etc…) Listen and work with patient Continue to emphasize with patient Maybe is often the best answer but hardest to get to.

15. QUESTIONS?

16. References Asscher, E., Bolt, I., & Schermer, M. (2012, June). Wish-fulfilling Medicine in Practice: a Qualitative Study of Physician Arguments. Journal of Medical Ethics, 38(6), 327-331. Ballard, D., Reed, M., Wang, H., Arroyo, L., Benedetti, N., & Hsu, J. (2008, December). Influence of Patient Costs and Requests on Emergency Physician Decisionmaking. Annals of Emergency Medicine, 52(6), 643-650. Brett, A. S., & McCullough, L. B. (2012, January 11). Addressing Requests by Patients for Nonbeneficial interventions. Journal of American Medical Association (JAMA), 307(2), 149-150. Burger, I. M., & Kass, N. E. (2009, April). Screening in the Dark: Ethical Considerations of Providing Screening Tests to Individuals When Evidence is Insufficient to Support Screening Populations. The American Journal of Bioethics, 9(4), 3-14. Ferrante, J., Shaw, E., & Scott, J. (2011, October). Factors influencing Men's Decisions Regarding Prostate Cancer Screening: A Qualitative Study. Journal of Community Health, 36(5), 839-844. Gregory, S. (2005, May 19). Preparing for Practice: Difficult Patient Requests. Update, 70(5), 80-84. Henry, L. A. (1998, September). Demand Management: The Patient Education Connection. Family Practice Management, 5(8), 65-70. Lorenzetti, R. C., Jacques, C. M., Donovan, C., Cottrell, S., & Buck, J. (2013, March 15). Managing Difficult Encounters" Understanding Physician, Patient and Situational Factors. American Family Physician, 87(6), 419-425. Maizes, V. (2000, February 1). Setting Limits on Demanding Patients. American Family Physician, 61(3), 881-882. Malm, H. (2009, April). On Patient Requests for Unproven Screening: Dim Guidance for Screening in the Dark. The American Journal of Bioethics, 9(4), 15-27. McKinlay, J. B., Trachtenberg, F., Marceau, L. D., Katz, J. N., & Fischer, M. A. (2014, April). Effects of patient Medication Requests on Physicians Prescribing Behavior: Results of a Factorial Experiment. Medical Care, 52(4), 294-299. Paterniti, D. A., Fancher, T. L., Cipri, C. S., Timmermans, S., Heritage, J., & Kravitz, R. (2010, Feb 22). Getting to "No". Archives of Internal Medicine, 170(4), 381-388. Silberstein, N. (2010, January). Understanding and Managing Patient Expectations. Podiatry Management, 109- 112. Toiviainen, H., Vuorenkoski, L., & Hemminki, E. (2005, March). Physicians' Opinions on Patients' Requests for Specific Treatments and Examinations. Health Expectations, 8(1), 43-53.