Saying No

I said no when Nora Williams asked me to order a CA 125 blood test the other day. She is worried about ovarian cancer, not because of any family history, but because she, in her own words, just has the worst luck. She is an anxious woman, and I would have loved to help relieve her anxiety, but I couldn’t.

I said no when Mark Michaud asked for an antibiotic, even though he was miserable after several days of cold symptoms which had by now turned into a severe and productive cough with thick, yellow sputum.

I even said no when Jim Westerdahl asked for an MRI of his back after his sciatica attack cleared on prednisone. “I just want to know what’s going on in there”, he said, “so I know what to expect.”

I seem to be saying no a lot lately. More and more often, patients present with requests for specific tests or treatments, sometimes as a direct result of searching online for ways to screen for, diagnose or treat disease.

Nora Williams’ fears of ovarian cancer cannot be allayed by a CA 125 test. Women often ask for it, but the sad truth is that for an average risk woman without a family history of the disease, a positive test means ovarian cancer only 20% of the time, and only 50% of early ovarian cancers cause a rise in this particular tumor marker. The real usefulness of this test is to follow an already advanced ovarian cancer for recurrence after treatment.

Mark Michaud, like many other people, wishes antibiotics would work on viral infections, but they don’t. Twenty years ago I might have treated his type of bronchitis with an antibiotic, but now we know that colored phlegm does not necessarily mean an infection is bacterial.

Poor Jim Westerdahl. Whether an MRI showed a herniated disc or not, that would not help predict his risk of recurrence. It has been said that 10% of healthy people have MRI evidence of significant disc disease, but no symptoms. His symptoms were already gone, so he didn’t need any treatment, and a $1500 MRI would not help predict future symptoms any more than flipping a coin.

Sometimes I say no when patients want disability parking placards, electric scooters or narcotic pain medications when it really is in their best interest to push themselves a little harder.

I say no when patients ask me to write prescriptions in their name for an uninsured family member, and I say no when patients ask for expensive, new medications they have seen advertised on TV when there are effective, tried-and-true generics that work just as well.

I also say no when patients call in with a request for a prescription when they have self-diagnosed something I haven’t seen them for many times in the past.

Saying yes is often faster in the moment, since a no requires a thoughtful explanation, but my job is to consider the long-term consequences of every clinical decision. As a physician I have the freedom to ignore the guidelines and the scientific evidence that’s out there when I think my patient doesn’t fit the usual pattern. We need to be careful with that power if we want to keep it.

4 Responses to “Saying No”

  1. 1 fnp2011 December 7, 2009 at 12:49 pm

    Good for you. A lone voice in the “wilderness” (country) showing the world how healthcare reform should really happen. Primary care providers saying no to unnecessary tests and treatments, saving money for the patient (lowering health care costs)and providing individualized treatment plans. Kudos.
    BTW: as a learning point for me (a student FNP who plans to practice in a rural area), what is the best way to differentiate the bacterial bronchitis that can follow the original viral disease?

  2. 2 isaac December 11, 2009 at 6:20 pm

    If patients were responsible for the cost of their healthcare, like every single other facet of life, a lot of this stuff would disappear. How many people ask for an expensive diagnostic test on their car, just in case.

    • 3 FNP Student December 11, 2009 at 11:03 pm

      Exactly. I don’t have insurance at the moment, and when I had right flank pain I went to my MD, who is great and charges me $50 for a visit. He did a urine dip for blood (neg)and sent to the ED lab to get a CBC ($29) normal. We then decided to wait to see if the potential kindney stone would pass, gave me a sieve, script for pain and sent me home. CT scan only if pain got worse, it passed. Total cost $79. What if I had gone to emergency room, good grief, it doesn’t bear thinking about. I like the idea of medical savings accounts. A penny pinching Dutchman like myself can control my own healthcare costs!

  3. 4 Steph January 13, 2010 at 10:08 pm

    Very admirable!

    As long as the “No” is always accompanied by a sensitive explanation which, in your case, I’ve no doubt it is.

    Congrats from a suitably impressed patient 🙂

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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