Clinically inappropriate patient demands of oncologists happen infrequently

Although many physicians cite “demanding patients” as the reason for high medical costs due to unnecessary tests or treatments, a new study conducted at outpatient oncology centers found that only 1% of 5,050 patient-clinician encounters resulted in a clinically inappropriate request, of which very few were complied with by physicians, according to a study published by JAMA Oncology (2015; doi:10.1001/jamaoncol.2014.197).

Physicians often contend that malpractice lawsuits force them to practice defensive medicine and that the proliferation of information has induced patients to demand expensive tests and treatments. However, few data exist about demanding patients, the clinical appropriateness of their demands, and clinicians' compliance with their requests, according to the study background.

Ezekiel J. Emanuel, MD, PhD, of the University of Pennsylvania, Philadelphia, and coauthors analyzed interviews with clinicians immediately after they visited with patients to assess whether a patient had made a demand, the type of request made, and the clinical appropriateness of it. The interviews were conducted at outpatient oncology facilities at three Philadelphia-area hospitals between October 2013 and June 2014.

The authors evaluated 5,050 patient-clinician encounters involving 3,624 patients and 60 clinicians. Most of the patients were women and the most common cancer was hematologic.

Overall, 440 (8.7%) of the 5,050 encounters included a patient demand or request, such as for imaging studies, treatments, or tests, and physicians complied with 365 (83%) of them. Of all 5,050 patient-clinician encounters, 316 (6.3%) had a clinically appropriate patient demand or request, while only 50 (1%) of the encounters included a clinically inappropriate request.

Of the 50 clinically inappropriate demands or requests, clinicians complied with seven of them, which means that in just 0.14% of encounters (7 of 5,050) did clinicians order a test or treatment based on a clinically inappropriate request.

“At least in oncology, ‘demanding patients' seem infrequent and may not account for a significant proportion of costs,” the study concluded.

In a related editorial (doi:10.1001/jamaoncol.2014.185), Anthony L. Back, MD, of the Seattle Cancer Care Alliance, wrote, “In this issue of JAMA Oncology, Gogineni and colleagues report on their empirical inquiry into patient demands, a nemesis that proves to be more mythical than real.”

“The real point of the study by Gogineni [and colleagues], however, is this: we have to stop blaming patients for being demanding. In reality, it is hardly happening. The myth of the demanding patient is more about our own responses and how lackluster communication skills can contribute to difficult situations that stick in our throats and in our memories. And when we have calmed down enough to look up, we see that what is really happening between patients and physicians these days is something quite different,” Back continued.

“It is possible that what the study by Gogineni [and colleagues] documents is a point in the evolution of the patient-physician relationship when both sides recognize the complexity of cancer care belies a simple fix. Perhaps this ‘negative' study is pointing to an important truth: that we need to redirect our attention from the myths that are distracting us,” Back concluded.

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