How would you deal with someone who is insisting to have mammogram without indication?

From:
Sent: Tuesday, November 29, 2011 12:08 PM
To: info@oscehome.com
Subject: Conflicted roles Dear Doctor Al Imari, Could you please give more idea about dealing with conflicts as there is only one phrase you have mentioned in the remedy part, can you elaborate what to be explained about the conflict in the case and what should we inform as a doctor about what we could do. This is from OSCEhome ebook “How To Unlock Difficult Medical Encounters”. To be more precise how would you deal with someone who is insisting to have mammogram without indication or a mother who is asking why her teenage daughter was in your clinic etc.

Kind regards
Ravi

Hello Ravi,

For "how would you deal with someone who is insisting to have mammogram without indication ":

1- Address their needs with respectful, empathic, and generous care directed towards physical and emotional comfort. Ask why she is really concerned to have the mammogram now? Hidden issues? Educate the patient about the limited benefits of mammogram, as the fact is that the younger the women is, the more difficult to efficiently read the mammogram films as younger women have more glandular breasts which limits the benefit, and its risk of radiation.

2- Set limits of your “Contract” with the patient:
 1) Provide written instructions: brochures, web sites about the recommended guidelines. Discuss a risk-benefit balance
 2) Set follow-up appointments.
 3) Set limits on phone calls.
 4) Set limits on prescriptions refills.

3- Emphasize the patient responsibilities:
 1) Understanding the nature and characteristics of their health problem.
 2) Behavior change and adherence to therapy. Self examination and periodic physician exam.
 3) Fulfilling his/her part of the “therapeutic contract”. Negotiate a plan TOGETHER. Don't be confrontational. The agreed upon plan is for her best interest and you gain nothing for ordering the mammogram or not.

4- Avoid making promises that you cannot keep (e.g. nursing or insurance problems). Apart from reconsidering the issue on next appointment.

5- Remind the patient that available time is limited. “You certainly have a lot of important problems, but since our time is so short, I’d like to get back to your …cc ”

6- Do not take credit for remissions in the patient’s symptoms, because you will be blamed for a relapse in the future. Note: Sometimes physicians order tests to relief anxious patients, but try to avoid that during OSCEs. ----------------------------------------------------------------------------------

About "a mother who is asking why her teenage daughter was in your clinic":

1- Clearly communicate to the patient, individual, and institution your double role right from the beginning. “Mr./Ms. …, although I am your doctor and I am obliged to do all my best to serve your interests, I also have other obligations and duties by profession or law that might limit my obligation towards you. I’ll do my best to serve both obligations.

2- Clearly explain what the conflict is in this case. "Your daughter is mature enough to take care of herself and, by privacy and professional laws, I cannot give you any relevant information."

3- Clearly inform him/them about what can you do. "I cannot help you here and I recommend discussing this issue directly with your daughter. Please excuse me. I don't want to waste your time as well as other waiting patients' time." and end the encounter. If she continues to ask in different ways, just keep saying “Discussing this issue directly with your daughter.”

Hopefully this answers your questions.
Have a nice day.
Al