Very few patients are unreasonable so oncologists "have to stop blaming patients for being demanding."
Sixty clinicians were interviewed at three Philadelphia-area hospitals providing cancer outpatients services, and the physicians who had received the tiny proportion of inappropriate demands almost always refused to act on them.
A clinically inappropriate test or treatment was agreed to in just 0.14% of patient encounters. In spite of this, "physicians often contend," say the researchers, "that the proliferation of information has induced patients to demand expensive tests and treatments."
The study, published online first in JAMA Oncology, examined a total of 5,050 patient-clinician encounters involving 3,624 individual patients.
Most of the Philadelphia patients (2,427) went to The Hospital of the University of Pennsylvania, with the remainder split almost evenly between going to the Presbyterian Hospital (559 patients) and the Pennsylvania Hospital (638).
Of the 60 clinicians interviewed, 34 were oncologists, 11 were oncology fellows and 15 were nurse practitioners or physician assistants.
The researchers say there has been little research to quantify how well the reality of patient demand supports a widespread perception that it is high. They explain that "physicians tend to attribute high health care costs to lawyers, insurers, drug companies and patients rather than themselves." They add:
"Physicians may feel obligated to satisfy patients' demands to protect the physician-patient relationship, especially because reimbursement increasingly depends on patient satisfaction, and to prevent patients from switching practices."
But in reality, these concerns are unfounded, the study suggests. Conducted by Dr. Keerthi Gogineni from the hematology-oncology division at the Hospital of the University of Pennsylvania, and co-researchers, it found that, out of all the 5,050 patient-clinician encounters:
- Appropriate demands or requests by patients were made 316 times (6.3% of encounters)
- Inappropriate demands or requests were made in only 50 of the encounters (1%).
Of the 50 demands or requests deemed clinically inappropriate, clinicians complied with seven of these - which translates to just 0.14% of encounters resulting in a test or treatment purely for the benefit of a patient's demand, but clinically not needed.
"At least in oncology," the authors conclude, "physicians' perceptions that demanding patients induce a large quantity of clinically inappropriate tests and treatments seem inaccurate."
Gap between clinicians' perceptions and reality
The study paper discusses the reasons why the results should show such a small proportion of consultations involving unreasonable demand while the doctors seem to think the problem is much larger.
"Patient demands and requests are infrequent but loom large in physicians' minds," the authors write, saying that a possible reason why may lie in the fact that "patients' demands or requests, while infrequent, are emotionally salient."
Doctors may be feeling a burden from the demands that are deemed reasonable, too: "Even requests for clinically appropriate interventions can suggest lack of trust in the clinician and threaten the therapeutic relationship."
Such requests, the paper's discussion continues, "probably take additional time during the encounter."
And clinically inappropriate requests "likely require substantial time to explain why they are inappropriate."
Unreasonable demands may also loom large because of a guilty feeling about acting on them, even though, as this study suggests, physicians rarely comply with them. The paper says:
"In the few cases in which clinicians order a clinically inappropriate test or treatment, they may feel as if they have acted unprofessionally."
Legacy of old paternal values in medicine
An editorial article accompanying the research paper, written by Dr. Anthony Back, an oncologist at Seattle Cancer Care Alliance in WA, says cancer care specialists "are witnessing a tectonic shift in the dynamics between patients and physicians around cancer."
He says that this change is pushing away an "old paradigm" of the "paternalistic physician" - but that its legacy explains why the "demanding patient myth" persists. Dr. Back says:
"The paternalistic physician told the patient what to do, and the patient who did not like it had to resort to a demand to cut through the physician's cloak of authority."
The dynamics have changed, however, thanks to better access to information, says Dr. Back. He writes:
"Patients used to come to oncologists seeking information about their cancer and recommendations for treatment. Before the Internet, they did not have any other sources.
"But now in the age of Wikipedia, patients and their families usually come prepared. Patients now begin shaping their preferences and decision-making before they set foot in the oncologist's office."
Dr. Back says he understands the disproportionate perceptions: "The demanding patient leaves us with vivid memories, and it is an easy move to pin them (unjustly) with the blame for runaway costs."
However, he says, the real point of the study from Dr. Gogineni is that "we have to stop blaming patients for being demanding."