Conversations in the emergency department can be challenging, especially when we need to say "no" to patient requests. Let’s explore why this is difficult, the importance of having a script, and a framework for handling these conversations.
Why Saying "No" is Challenging
As healthcare providers, we tend to want to please patients and avoid dissatisfaction naturally and this can impact our decision-making. Some of this is how we’re wired, but there’s also the reality of the impact of satisfaction scores. Depending on where you work and the culture, satisfaction surveys can be your friend or, more commonly, your foe.
Another reason saying “no” can be challenging? Dealing with constant pushback can be exhausting, and the temptation to say "yes" to avoid hassle is strong. Saying "no" can sap energy; it’s so much easier to concede.
The Importance of Having a Script
A script helps conserve energy, ensuring that difficult conversations are handled consistently. When facing challenging conversations frequently, having a rehearsed script can prevent miscommunication or errors.
Practice Makes Perfect
Let’s tackle a common scenario: antibiotics for a viral upper respiratory infection (URI.) When patients request antibiotics for viral infections, the conversation typically involves explaining the ineffectiveness of antibiotics and potential harm.
Understanding the patient's desire for a quick remedy, particularly in the form of antibiotics, is crucial. The patient’s request for antibiotics is often driven by the prevailing belief that a prescription is key to feeling better.
“I’ve been dealing with a week of coughing, a runny nose, and sinus congestion. My doctor always prescribes a Z-pack; can I get one of those?”
Our standard response echoes the medical truth: "Antibiotics won't improve a cold; in fact, they can cause harm like diarrhea and toxic megacolon."
We meticulously outline the potential side effects, cite scientific evidence, and even provide printed resources like Choosing Wisely. While some patients respond positively to logical explanations, the reality is that pushback and irritation are the norm.
The patient, amidst our well-intentioned logic, is often internally pleading, "Just say YES, and let’s be done with this." The disconnect lies in the clash between our logical discourse and the emotional experience of being denied what they seek. Balancing the art of saying "no" with emotional understanding becomes imperative, recognizing that logic alone may not effectively address the emotional challenges patients encounter.
One Framework for Handling Requests
There must be a basic assumption that you respect the patient and their interests. Do not dismiss or invalidate. Think of it this way: If you hadn’t done all that medical training, you would probably have the same ask that they do.
Framework: Yes-No-Yes or a No Sandwich
Establish what you say "yes" to. This could be a commitment to avoiding harm and practicing medicine in accordance with your values. No: Clearly state "no" to the issue, not the person. Use "The" statements instead of "You" statements to shift from judgment to discernment. Yes: Provide a viable alternative. Assure the patient it doesn't look like a bacterial infection and suggest an alternative plan.
Framework Example:
- Yes: “I am saying yes to embracing the Hippocratic oath and practicing medicine following those values.”
- No: “The idea that antibiotics effectively treat this kind of infection is common, and to the best of our knowledge, it’s just not the case. You’ve told me that you’ve gotten better in the past when you’ve taken a Z-pack (validation). This is a common experience for many patients (social proof) - feeling better after starting antibiotics when they have a cold or recent sinusitis. In my experience, here’s what I see happen with that: those who do and don’t take the antibiotics end up having the same duration of illness and those who get antibiotics get a whole lot more diarrhea.”
- Yes: “Good news, it doesn't look like a bacterial infection or anything serious right now. What I’ve found works well for this situation is X plan…”
Expect Pushback
Respond with kindness and empathy. Acknowledge their frustration and gently reiterate the potential harm of antibiotics.
“So you aren’t going to write me for antibiotics???”
- Pushback Response Option 1: Stay firm with your boundaries, but guide the patient to acceptance of the situation with kindness and compassion. You may respond: “I hear you! And I know it can be frustrating (empathy and compassion). It’s a common question I get every day (social proof), and to the best of our knowledge, antibiotics do more harm than good with what you've got going on.”
- Pushback Response Option 2 “Yeah, you probably did feel better. I think you probably would have felt better even without that Z-Pak last time. Now, maybe the situation was different than what your doctor saw last time, but I know for what you're here with now, antibiotics are not going to help.”
Elevating Effective Communication Skills for Better Patient Care
Mastering the art of saying "no" requires a delicate balance of authenticity, firm boundaries, and compassionate communication. Using well-crafted scripts based on these frameworks ensures that difficult conversations are handled with professionalism and consistency. Embracing these communication tools can lead to better patient understanding and satisfaction.
