According to a recent study published in JAMA Oncology, medical intervention was demanded or requested by 8.7% of patients with cancer, of which, only 11.4% of requests or demands were deemed inappropriate—contrary to commonly held perceptions by clinicians.1
The survey included 3,624 unique patients and 60 clinicians, including oncologists, oncology fellows, nurse practitioners, and physician assistants, who practiced at three Philadelphia-area hospitals.
Immediately following a patient–clinician encounter or after a half-day clinic session, the clinician was privately interviewed by a trained research associate. United States census data from 2010 were used to determine patient socioeconomic status according to zip code.
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In the analysis, most patients were female (58.7%) and white (69.4%). Many used private insurance (56.3%) or Medicare (40.6%), and the household income was $50,000 to $100,000 for 57.3% of patients.
Cancer types included breast, gastrointestinal, lung or head and neck, genitourinary, hematologic malignancies, with most patients having stage I to III disease (64.4%) and receiving active anticancer treatment with a curative intent (64.7%).
During 5,050 patient-clinician encounters, 8.7% of patients demanded or requested intervention including imaging studies (49.1%), palliative treatment (15.5%), laboratory tests (13.6%), genetic or chemotherapy-sensitivity analyses (5.2%), and clinical trials (6.8%).
Most demands or requests were deemed medically appropriate by the clinician; 11.4% were felt to be inappropriate and 16.8% were equivocal. Out of the inappropriate requests, clinicians complied with 0.14% of inappropriate requests and 64.9% of the equivocal requests.
Receiving anticancer therapy was associated with demanding or requesting an intervention (odds ratio [OR], 1.74; 95% CI, 1.26 to 2.41), with patients with stage I to III disease more likely to make a request or demand (OR, 1.78; 95% CI, 1.34 to 2.36) rather than patients with metastatic disease (OR, 0.76; 95% CI, 0.49 to 1.19). In addition, patients with lung or head and neck cancer were more likely to make a demand or request an intervention compared with patients with breast cancer (OR, 1.70; 95% CI, 1.23 to 2.35).
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Interestingly, the patient–clinician relationship was a predictor of demanding or requesting an intervention; a patient whose relationship with the clinician that was rated as fair or poor was significantly associated with demanding or requesting an intervention (19.8% vs. 8.2% with excellent or very good relationship; OR, 2.74; 95% CI, 1.12 to 6.73; P = 0.004).
In an accompanying editorial, Anthony L. Back, MD, of the Fred Hutchinson Cancer Research Center at the University of Washington in Seattle, WA, commented that, “The demanding cancer patient looks less like a budget buster and more like an urban myth.”2
Dr. Back hypothesized that the firmly held belief of the demanding patient—an infrequent occurrence—may be a result of a memorable experience, a difficult situation, or a convenient target for larger clinician-related issues. In addition, he highlighted that clinicians should identify emotion as a core communication skill.
“Your patient who is demanding something is actually upset and hurting in a way that is overwhelming their coping skills.”
References
- Gogineni K, Shuman KL, Chinn D, et al. Patient demands and requests for cancer tests and treatments. JAMA Oncol. 2015;1(1):33-39.
- Back AL. The myth of the demanding patient. JAMA Oncol. 2015;1(1):18-19.
