Lee A. Resnick, MD, FAAFP
The impact of patient expectations and pressures on high utilization rates in this country is a subject of significant discussion but surprisingly little study. A literature review produces scant evidence of scientific inquiry in this area.
And yet, most clinicians would say that patient expectations are perhaps an even stronger motivation for utilization than fear of malpractice suits. In an ever-competitive, service- oriented industry like urgent care, this can only be exaggerated.
So, what are the underpinnings of patient expectations when it comes to testing? Why are our patients so willing to dismiss the evidence or tilt the decision-making scales in favor of testing? Are there clues in the data that might help reinvent the way we manage patient expectations, or would that be futile, given the vulnerability and irrationality of the human mind?
In researching this column, I came across a fascinating study about why our patients are so enamored with testing and convinced of its potential virtues that they ignore any rational discussion to encourage otherwise. Done by researchers at the University of Maastricht,
The Netherlands, it involved 224 family practice patients who were questioned about their expectations for testing regardless of the purpose of their visit. A full 26% expected testing regardless of the physician’s recommendation. Why? Some of the participants felt that testing was indicated for certain conditions, such as recurrent disease. Others felt that tests were necessary and effective for providing a “certainty of good health.” The impact of the media and other social influences was noted, as was the general “appreciation” for the physician who takes an “active policy” in clinical decision-making and testing.
I found that last rationale to be of most interest. It is not lost on me that many of the avoidable “bad outcomes” in medicine are due to tests not ordered and interventions not made. It should be obvious to anyone why patients may feel driven to ensure that they are not victims of these avoidable mistakes. Conversely, little public outcry is ever heard about the risks of over-testing and over-utilization. That topic has been discussed at length within clinical circles but appreciation of the risks has hardly trickled down to patients. It is no wonder, then, that “active” testing is viewed as a favorable physician trait, while conservative approaches are viewed with skepticism.
As a practical clinical matter, the testing paradox is a common daily encounter that creates significant anxiety in both patients and clinicians.m The anxiety is only amplified in a brief urgent care encounter between two strangers. Most of my “test heavy” colleagues are deemed “excellent” clinicians and admired by their patients, even when the evidence says otherwise. The productivity demands of the day do not leave room for lengthy conversations with every patient about false-positives and positive predictive values. A real “risk-benefit” analysis is a complex calculation that requires a near instantaneous evaluation of the existing evidence, personal fund of knowledge, and fund of experience. While imperfect, it is what we urgent care providers spend 7 years educating ourselves to do, and years of practice perfecting.
Culling that down into 2 or 3 sentences in the hopes of convincing a patient is almost always fruitless. I have found only one practical way to manage the competing expectations from patients about testing within the scope of daily practice. I present the evidence and “experience-based” case for the direction I would like to take without ignoring a patient’s own expectations. With about 80% of patients, a careful review of my clinical decision-making that also addresses any concerns they have expressed or anticipated works. At the end of my clinical decision-making recap,
I ask every patient 2 questions: “Does that make sense to you?” and “Does it adequately address the concerns you came in with today?” While most of my colleagues prefer the “don’t ask don’t tell” approach, I find that most patients are already comfortable with my explanation, and those who are not are worth identifying BEFORE they leave the office. This strategy gives me the opportunity to negotiate a direction that is still clinically reasonable with individual patients while avoiding unnecessary testing for the majority.
Managing patient expectations in a productivity- and service oriented environment like urgent care remains a daunting challenge, but application of a disciplined, systematic approach can ease some of the burden. Anticipating patient concerns and agendas is a useful way to ensure that you have a fair opportunity to negotiate a clinically reasonable approach to each individual’s care without the need for “knee-jerk” testing.