Presumably, every doctor wants to create healthcare experiences that garner positive feelings (and positive reviews) from patients. Yet at the end of the day, high-quality care trumps customer service. Bound by the Hippocratic oath, a doctor’s primary responsibility is to act in the best interest of the patient. And sometimes the best thing a doctor, nurse, therapist or other provider can do is say no.
So when and why do doctors turn patients down, and how do they go about doing it? Here’s what five clinicians had to say.
Facial plastic and reconstructive surgeon, Aviva Plastic Surgery and Aesthetics, Atlanta
Most commonly, I say no to established patients when the elective treatments they are seeking are not the best way to address their particular concerns. Since most of my practice is dedicated to elective and cosmetic procedures, I place lots of focus on proper patient selection. The patient interested in purely cosmetic rhinoplasty is different from the patient with a facial laceration; they have different motivations and preset expectations before they ever arrive at the office.
I remain vigilant for patients with body dysmorphic disorder, as these patients are not well treated with surgery and require psychological and psychiatric treatment. I am also seeing more and more young patients these days with so-called “selfie dysmorphia,” or very unrealistic expectations of appearance, bred within the Snapchat-filtered, Photoshopped and Instagrammable culture of today. As incredible as it sounds, some patients come in and expect absolutely no wrinkles in their neck — everyone has those — and completely poreless and flawless skin. These patients tend not to be great treatment candidates, and I often cannot meet their expectations. In these situations, we move forward to resetting expectations or decide against treatment altogether.
Beyond this, some people are not good treatment candidates due to personality issues. When people are rude to staff, disruptive or dishonest, these are red flags potentially signaling more trouble down the road. I love providing high-quality and thorough care to my patients and try to minimize unnecessary disruptions, especially in the form of unnecessarily difficult patient interactions.
Ian J. Palombo
Clinical director of Denver Mental Health Collective, Denver
EdD candidate, LPC
I receive several requests a month for letters to “certify” emotional support animals, for both established and unestablished patients. Though emotional support animals can be a terrific help to the healing process, it is vitally important to differentiate between situations in which this qualification is beneficial for the patient, and those in which it may be detrimental. Emotional support animals can live in otherwise pet-free apartments, fly on airplanes and avoid pricey pet deposits and pet rent, and many times the requests I receive are from individuals looking to take advantage of these privileges that regular pets do not enjoy.
In order to qualify for an emotional support animal, individuals have to have a verifiable psychological disability that substantially and markedly interferes with daily functioning. As a licensed mental health professional, it is my responsibility to diagnose, verify or substantiate said disability. It’s unethical, irresponsible and in some states illegal to provide a letter for a person who is not disabled.
When I receive requests for letters from individuals who aren’t seeking care for their stated disability, I simply tell them no and provide education on the definition and function of emotional support animals, as well as the impact their actions could have on individuals that actually need these animals. There are also instances where I deny requests from established patients because their presenting issue does not qualify as a mental disability under the ADA. In these cases, I typically explain that documenting a disability they don’t have can have very serious long-term consequences, such as higher life insurance premiums and the possibility of being denied health insurance for a preexisting condition.
Chiropractic physician, Tampa, Florida
In my chiropractic practice, I frequently have to say no to patients who want to dictate their own treatment. The mindset of this kind of patient can even be potentially a danger to themselves in certain scenarios. One example I can clearly recall was when a new patient came to my practice with lower-back and right-leg pain that she was certain was sciatica. She said she had this type of pain before and was essentially telling me a play-by-play of how she wanted me to treat her that day. During her examination, I noticed her leg was twice the size of the other one, red in coloration and hot to the touch. I immediately sent her to the ER to confirm my suspicion that it was a clot, and sure enough, she was quickly diagnosed and treated for a deep vein thrombosis. This condition can be fatal if the clot breaks off and makes it to the lungs.
When the patient initially walked into my office, she wanted me to do a quick spinal manipulation, thinking this would fix her “sciatica.” I had to be firm in telling her no despite her initial disappointment. However, once I explained to her my findings and why she needed to be referred out, she was very appreciative of how I handled this situation.
Dentist, Jupiter, Florida
I actually get a kick out of when a patient tries to dictate treatment and I have to tell them there is actually a better way to treat a given issue. What the patient may perceive as a problem may or may not be true, but there’s often a better way to treat the issue. For example, someone with severe periodontal disease or gum disease may look at their teeth and ask how we can make them whiter, when what they really need is treatment for the root issue, their gums.
The same can be said when somebody comes in with a broken tooth and asks if the broken piece can simply be glued in. The important part is not to simply say no, but to use this scenario as an opportunity to educate the patient and help them realize there’s more going on than what they may perceive or ask for. If there is pain in the tooth, there is a reason for that pain; an antibiotic or pain pill will not make it go away permanently. So while I always listen to patients, I also educate them on the proper diagnosis and treatment plan so they know what is really needed long-term.
Internal medicine specialist and primary care physician, MemorialCare Medical Group, Irvine, California
With the endless amount of medical information that is available on the internet, it’s not uncommon for patients to come to me with their symptoms along with their theory about the cause. However, much of that information needs to be filtered. Some of the information from the web may not be applicable. For example, I saw a patient this morning complaining of some throat symptoms. He requested to see an ear nose and throat specialist; however, upon further questioning, I realized that it would be more appropriate to send him to a gastroenterologist instead. I gave him a medication for his esophagus in the meantime until he could get in to see the specialist.
Another patient came to me requesting some steroid cortisone pills to treat her symptoms, but due to the potential side effects of steroids, I felt that it would be best to treat her symptoms with a more conservative approach. I gave her two medications that have fewer potential side effects than steroid pills would have. If her symptoms persist, I may eventually need to give her a short course of steroids. However, at that point, I would feel comfortable knowing that she had already failed to improve with the first line of therapy.
In both examples, I was able to redirect the patients to a more appropriate treatment plan. I also explained to the patients my rationale for doing so. Of course, this only works if the patients trust me. This is one reason why it is important for a patient to establish a good rapport with their primary care physician. This relationship is based on mutual trust and is the foundation for living a long and healthy life.
Responses have been condensed and lightly edited.