The Myth of the Demanding Patient.

In this issue of JAMA Oncology, Gogineni and colleagues report on their empirical inquiry into patient demands,1 a nemesis that proves to be more mythical than real. The study hypothesis—thatpatientdemands for treatmentsandscansdrove unnecessarycosts—was spectacularly unconfirmed when using data collected from physicians themselves. Only 8% of the patient-physician encounters at 3 cancer centers in Philadelphia involved a patient “demand,” and the majority of those “demands” were viewed by the physician as “clinically appropriate.” Suddenly, the demanding cancer patient looks less like a budget buster and more like an urban myth. In the wake of these findings, the question now deserving of our attention is why does the myth of the demanding patient have so much traction? Surprisingly (as the authors note), no prior empirical study exists to tally patient demands in cancer care, which makes the existence of the demandingpatientmyth evenmore curious.Mynewhypothesis is that these findings saymore about our ownclinical sensibilities than what they reveal about our patients. We clinicians often, inmyown experience, viewpatientswhomake a request that is surprising, unjustified, or forceful (eg, a “demand”) as (1) hard to deal with; (2) memorable despite their infrequent appearance; and (3) a convenient target for thebigger, complex, seemingly unsolvable problems we face. When patients make requests forcefully, it is easy for an unskilled clinician to be pushed off balance. A forceful request often carries an undercurrent of hostility that throws oncologists who are used to being treated with deference. We do not like this, and consequently, hostility from the patient tends to provoke hostility from the clinician. For clinicians who have not been trained to detect and respond to emotion as a core communication skill, it is easy to fall into the trap of responding defensively or angrily. From the outside, this skill can look like magic because it is subtle—it starts with self-monitoring.2 The key skill is to notice when you are irritated, and rather than blurt out your defense, pause and step back for a moment. You will then recognize that your patient who is demanding something is actually upset and hurting in a way that is overwhelming their coping skills or, much less often, has a personality such that they deal with everyone in their lives by making demands. A skilled clinician, after the pause, would start with an empathic remark (“Hmm, sounds like this is really important to you”) and modulate accordingly.3 For a patient who is really upset, the emotionally intelligent oncologist might offer more empathy (“I get the feeling you are worried...”) and uncover the real issue (“Yes doctor, I’m just scared”); and when the emotional tone fades, try the information again (“Could I step back—I’ll try to do a better job explaining my recommendations”). Although demanding patients are not common, they often figure prominently in our memories because our cognitivebiases tend tospotlightoutliers.4One reason for this is that a demanding, dissatisfied, unhappy patient can tap into our own unhappiness about not being perfect, our own disappointmentaboutnot saving theday, andourowndismayabout notbeingappreciated. Ifwedonothaveourownskills to emotionally self-regulate and recharge,we tend to give these cognitive biases more influence than they merit. And we have started our day with stress, multitasking, and inadequate sleep—all very common. It is even easier to let our cognitive biases run rampant. A commoncognitive bias,misattribution bias, is particularly relevant for this discussion. The demanding patient leaves us with vivid memories, and it is an easy move topin them(unjustly)with theblame for runawaycosts. The real point of the study by Gogineni et al,1 however, is this: we have to stop blaming patients for being demanding. In reality, it is hardly happening. Themyth of the demanding patient is more about our own responses and how lackluster communicationskills cancontribute todifficult situations that stick in our throats and our memories. And when we have calmeddownenoughto lookup,wesee thatwhat is reallyhappening between patients and physicians these days is something quite different. The demanding patient myth reflects an old paradigm of patient-clinician interactions: thepaternalistic physician told the patientwhat to do, and the patientwho did not like it had to resort to a demand to cut through the physician’s cloak of authority.5 But that old posturing is receding in the face of a new dynamic. We are witnessing a tectonic shift in the dynamics between patients and physicians around cancer.6 Patients used to come to oncologists seeking information about their cancer and recommendations for treatment. Before the Internet, theydidnothaveanyother sources.Butnowin theageofWikipedia, patients and their families usually come prepared. Patients and families seek and absorb information from websites, textbooks, their ownmedical records, or other patients, all unmediated by clinicians, and they come to visits to verify what they have heard, ask questions, and gain from the physician’s clinical experience. Patients now begin shaping their preferencesanddecisionmakingbefore theyset foot in theoncologist’s office. The new dynamic is reflected in a fresh view of interactions from other empirical studies. What patients value from physicians is being guided to the information they need and want; being given that information at a pace they can absorb; Related article Opinion