Should doctors comply with all patient requests?

American doctors are increasingly being paid according to patient satisfaction. According to a report in Forbes, 2% of primary care physicians’ pay is now based on “patient satisfaction metrics” and 1% of specialist physicians’ pay.

Does this mean that doctors should agree with every request from a patient? The authors of a recent article in JAMA Internal Medicine respond with a qualified No. “Clinician denial of some types of requests was associated with worse patient satisfaction with the clinician, but not for others, when compared with fulfillment of the requests. In an era of patient satisfaction-driven compensation, the findings suggest the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.”

They found that 68% of requests included an explicit request by the patient. But the doctors only complied with only 85% of these.

Did refusal to comply upset patients?

Yes, if it involved physician referral, pain medication prescription, or laboratory test referral and the doctors received a lower satisfaction rating. However, when they refused to supply antibiotic prescriptions or imaging test referral patients accepted their decision without protest.

When doctors did refuse, their satisfaction ratings could be 10 to 20 percentiles lower. “The sizes of the associations suggest that clinicians who are less likely than their colleagues to fulfill patient requests for these services could face a penalty in satisfaction ratings, potentially affecting clinician career satisfaction, compensation, and handling of subsequent requests for these services.”

Doctors probably do not need scholarly research to realise that they will suffer financially if they refuse patients requests. So one down side, the authors note, is that “clinicians may be tempted to adopt a default approach of simply acquiescing to patient requests, including requests for low-value care, in an effort to maintain both favorable patient satisfaction ratings and clinical productivity targets.”

What doctors need, they suggest, is “Training ... to provide clinicians with communication approaches that foster a positive patient experience without simply acquiescing to requests for low-value care, thereby avoiding the harms of unnecessary evaluation and treatment, maintaining good stewardship of resources, and potentially enhancing clinician career satisfaction.

This research seems to have a certain relevance to the debate over the morality of conscientious objection. Some bioethicists, like Julian Savulescu, contend that refusal of services based on conscientious objection has no place in modern medicine. These findings suggest that the elimination of conscientious objection might be financially beneficial for doctors and medical health companies. Second, it might be associated with “low-value care”. Third, refusal of services like abortion and contraception could be turned into a positive patient experience if clinicians had better communication skills. 

MORE ON THESE TOPICS | conscientious objection, patient refusal, patient satisfaction

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