Thirty years ago, a doctor’s authority was rarely questioned. We went to them and trusted them to tell us what was wrong and what to do about it. Now, many of us arrive armed with information from friends or our own internet research, often requesting certain tests, or a particular prescription drug.

However, this change in patient behavior comes at a time when the push to control health care costs has never been more incessant. This situation frequently leaves physicians, particularly primary care physicians, squeezed between two conflicting sets of demands: those of their employers to control costs, and those of their patients, to fulfill certain requests.

This dilemma led one group of researchers to investigate the degree to which patient requests actually influence the behavior of their doctors. They suspected that patient requests for clinical services were both more common and more influential on physicians’ behaviors than currently acknowledged by health economists and health care administrators. The results of this study were published in the July 28, 2003 issue of the Archives of Internal Medicine. The researchers found that patient requests for clinical services were not only common, they exerted a powerful influence on physician behavior.

About the study

The researchers combined responses to patient and physician surveys with audiotapes of 559 visits to 45 physicians. All of the patients included in the study had either a new health problem or a significant health concern. The researchers measured outcomes in eight categories of patient requests for action on the part of the physician. These categories included:

  • Diagnostic tests
  • New medications
  • Specialty referrals
  • Physical examinations
  • Medication refills
  • Therapeutic procedures
  • Nonphysician referrals
  • Other

They also measured the number of patients making these requests, the number of physicians taking action on these requests, the degree of patient satisfaction with the visit, and physician perceptions of the visit.

The findings

The researchers found that 545 of the 559 patients in the audiotaped visits made requests for physician action. Of these, approximately 25% requested a complete or partial physical examination, 11% requested one or more new medications, 9% requested refills for current medications, 8% requested diagnostic testing, and 5% requested referrals to specialists.

In addition, the researchers noted that patients made these requests in approximately 25% of their visits with primary care physicians. Of visits to specialists, cardiologists had the fewest requests at only 8% of visits.

Finally, patients whose physicians failed to fulfill at least one or more of the patients’ requests for action reported significantly less satisfaction with their doctors visit than either those whose every request was fulfilled or those who made no requests at all. Physician satisfaction with the visit was not affected by patient requests, however, they did consider patients who made requests as being more demanding.

How does this affect you?

The study concluded that patients’ requests for clinical services do indeed influence the behavior of their physicians, particularly in terms of their referral and prescribing behavior. Because this was found to be true more for primary care doctors than for specialists, these findings have important implications for primary care practice.

One such implication is training of primary care doctors. Because these requests for services are now occurring in approximately 25% of primary care visits, training on how best to address these requests should be included as an integral part of physician education. It should also be incorporated into continuing medical education (CME) programs.

A second implication is that programs aimed at containing health care costs must address both the patient and the physician, as it may be unrealistic to expect a physician to refuse to provide clinical services on which a patient is particularly insistent. Efforts to make evidence-based medicine accessible to both physicians and patients may offer a promising new strategy for managing both the quality and the cost of medical care.