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How to Communicate with Patients Who Demand Unnecessary Procedures

A new method of talking to patients who ask for unnecessary or non-indicated procedures
April 13, 2017 | Comments

How do we improve communication about facts and evidence in the face of denial and disbelief?Recently, we presented a scenario in which two friends discuss whether one of them should buy a gun to protect his family. In the first iteration of this scenario, the friend contemplating gun ownership is lectured about the data that show that personal gun ownership is dangerous. In the second iteration, the individual who is asked about gun ownership attempts to understand his friend’s motivation for buying a gun, what it is that he fears, and what he hopes to accomplish. This second iteration employs a communication method we are working to develop and adapt for science denial: motivational interviewing (MI). You can find out more about motivational interviewing here.

In this edition of Critica Concepts and Methods we adapt the MI approach for the scenario of a physician and patient discussing a health decision. There are many cases in which patients take positions or make requests that are contrary to current medical recommendations. Examples include refusing to vaccinate a child, asking for antibiotics for a viral upper respiratory infection, or insisting on having an MRI scan to evaluate uncomplicated lower back pain.  It is commonly observed that some doctors adopt an authoritarian stance in such instances, believing that they can leverage their knowledge and training to guide the patient to the “right” decision. We see repeatedly, however, that patients often do not respond to this approach and can become angry and resentful if they perceive that their feelings and ideas are not being respected. 

How can physicians and patients discuss health issues in a way that maximizes mutual understanding while also ensuring that key treatment decisions are approached in an evidence-based manner? We will begin to answer this question using the example of a woman who is pregnant for the first time and is requesting that her obstetrician deliver her baby by Caesarian section (C-section). The current medical wisdom is that C-sections are not indicated unless there are specific complications to the pregnancy or risks to the fetus. Some pregnant women, however, fear childbirth or want to assert control over the situation surrounding labor and delivery and request elective C-section even in the absence of such indications. As in the earlier case of the two friends discussing the issue of gun ownership, we will first present this conversation as it tends to go and then we will present a version of the conversation that utilizes motivational interviewing to allow for a more effective dialogue. 

Scenario 1: The Authoritarian Doctor

The patient has just finished being examined by her obstetrician and is now dressed and sitting across from him in his consulting room.

Patient: Everything seems to be going okay, so far. I’ve decided I want to have a C-section. I hope that is okay.

Obstetrician (OB): No reason for that. You’re young and healthy and the pregnancy is perfectly normal. We wouldn’t want to put you and the baby at any risk.

Patient: I know, but I’ve discussed this a lot with Mike, my husband, and we agree that I should have a C-section.

OB: You know, what you are asking is just not possible. First of all, there is no reason for it. Second, there are all kinds of risks. And most important, your insurance company will never pay for it.

Patient: I know all that, but I still want a C-section. I have two friends in my position and they both had them and they were up and around in a week, without any of the tears and stuff you get with a regular delivery.

OB: If you have a C-section, the baby can have trouble breathing. And you can get an infection in your uterus and there is bleeding and blood clots and all the risks of anesthesia. And then you could have trouble with all your future pregnancies. It’s just not the right thing to do.

Patient: But everyone seems to be having c-sections these days. And with a good surgeon everyone does fine. It’s what I want.

OB: Well, I just can’t agree to do it. If you insist on that, you’re going to have to find another obstetrician to deliver your baby.

At this point the patient and her doctor are adversaries and their relationship appears to be on the brink of ending. What are the problems with the approach this physician has taken? First, we need to acknowledge that he is factually correct about most of the things he has told his patient. There is a consensus among specialist and experts that C-sections are not the preferred method of delivery for a healthy first pregnancy. It is almost always better to choose a non-surgical approach when one is available, regardless of the medical situation, because surgery always entails elevated risks. It is also unlikely that the patient’s insurance company would pay for a C-section in her case, leaving her vulnerable to enormous out-of-pocket costs.

But the doctor is not considering other facts that are also relevant to the situation. There are many well-designed studies that have examined characteristics of women who request elective C-sections without a medical indication. These women tend to underestimate the risks of a C-section and to be fearful of the pain of childbirth and its effects on the female body. By focusing his attention only on one set of medical facts—the risks and benefits of C-section versus vaginal delivery—the ignores an essential fact: that the woman in his office is not making a decision based on scientific calculation of risk but based on her perception of risks and her related fears and anxieties. 

Many of us have at times asked doctors to do things that are not medically sound or in our best interests. How physicians convey the science behind medical guidelines is often less a matter of convincing patients of the facts than understanding what is really on their minds. 

Scenario 2: A Sensitive Dialogue between Doctor and Patient 

Here is another version of the encounter between a women pregnant for the first time and her obstetrician. See how you think this compares to the scenario presented above. 

Patient: Everything seems to be going okay, so far. I’ve decided I want to have a C-section. I hope that is okay.

OB: May I ask what led you to that decision? 

Patient: Sure, well, my husband and I talked about it and you know it seems very safe and that way there won’t be so much pain from labor.

OB: So, if I understand you correctly, you are concerned about the pain of a being in labor and having a vaginal delivery. Is that correct? 

Patient: Of course I am. It looks terrible and every woman I know talks about how it’s the worst pain you can ever experience. 

OB: Well sure, there is pain involved and it can be comforting to commiserate. 

Patient: Well, isn’t it like that?

OB: Look, I’m not going to tell you it is painless and yes there can be a lot of pain, depending on how long labor lasts and a lot of other variables. But there are also ways of managing the pain, depending on timing and a few other factors. 

Patient: But you just said it’s very painful and it seems like there’d be no good reason to go through that when we have modern technology.

OB: Sure, but I wonder if you’ve heard of any risks or problems associated with having a C-section? 

Patient: Not really, what I understand is that it’s generally a pretty simple procedure. Isn’t that true?

OB: Well, it’s true that it’s not the most complex procedure, but the real reason we usually do C-sections is because we don’t have a choice. If the labor isn’t progressing and taking too long, for example, or we are worried about the baby being in any distress, then we have to it.  But generally, we try to avoid performing sections if it’s at all possible.

Patient: But why? It seems like such an obvious alternative. 

OB: Several reasons actually. The most important thing for both you and me is that you have the absolute best chance of having a healthy baby and that you are able to stay healthy during and after delivery. We want you to be able to go home with your new baby as soon as you can. I totally understand your fears, but there are definite risks involved in having a C-section and I want to be sure you know all about those as well. Let’s review them now, but I also wonder if you would be willing to read through some things I can give you about C-sections. Maybe you and your husband can do that and come back together so we can talk about it some more. Would that be okay with you?

Patient: Sure, I can try that. 

In this version, the doctor and patient wind up as collaborators trying to make the best possible decision together. The obstetrician has not hidden the fact that she favors a vaginal delivery if possible for a woman in this position, but she does several things that are different from the doctor in the first version. For one thing, she starts out by trying to understand what is motivating the patient’s wish to have a C-section. She acknowledges that pain is a part of labor and validates that concern. She tries to establish a common goal with the patient: the wish to deliver a healthy baby. She recognizes that her patient has discussed this with her husband and that she has therefore involved him in the decision. Finally, this doctor asks the patient if she is willing to consider all possible perspectives and expresses a willingness to continue the conversation.

Notice that the doctor makes few pronouncements and asks the patient only a few questions. This is consistent with the MI approach, which mainly involves restating and reframing what the patient says until both parties understand what the patient’s goals and values are.

There will be obvious objections to the second approach. It may take too much time, and physicians do not get paid to talk with their patients. Some patients may be more insistent than others, seemingly leaving the doctor with little choice than to make unilateral decisions about the best course.

On the other hand, we know that we pay a heavy price for following the wrong course: overprescribing antibiotics, refusing vaccinations, and undergoing unnecessary tests and procedures are all dangerous and expensive outcomes of breakdowns in the way that doctors and patients interact when making health decisions. How to reformulate those interactions so that the science involved ultimately prevails is precisely what we at Critica train people to do. 

Now we’d of course love to hear from you. Can motivational interviewing be adapted to improve the doctor-patient interaction and increase the likelihood of scientifically-informed healthcare decisions? As a healthcare professional, have you ever experienced these communication breakdowns with patients? As a patient, have you ever experienced these communication breakdowns with doctors? What have you done in these situations? What has worked well and what hasn’t? Comment below or contact us here.

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