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Comment & Response
July 2015

The Demanding Patient Revisited

Author Affiliations
  • 1Center for Healthcare Policy and Research, University of California, Davis, Sacramento
  • 2Department of Communication, University of California, Davis, Davis
JAMA Oncol. 2015;1(4):543. doi:10.1001/jamaoncol.2015.1105

To the Editor We read with interest the study by Gogineni et al,1 in which oncologists recalled a patient request or demand in less than 9% of 5050 visits. Furthermore, only 1 in 9 requests or demands was deemed inappropriate. The authors concluded that demanding patients are infrequent in oncologic practice. They contrasted their results with the findings of Kravitz et al,2 which identified patient requests for tests, referrals, or prescriptions in 23% of visits. To explain the discrepancy, Gogineni et al speculated that coding of transcribed audio recordings may exaggerate the frequency of requests relative to oncologist report, that “in California, primary care patients make more demands than cancer patients in Pennsylvania,” and that our study had fewer encounters and clinicians, “generating a selective sample.”1(p37)

Although we agree that “demanding patients” cannot be held responsible for a large share of cancer-related costs, the following qualifications merit attention. First, considering the high stakes of a cancer diagnosis and patients’ deep dependence on their oncologists, a rate of requests approaching 1 in 11 seems anything but low. Second, physician recall (especially when elicited up to 4 hours after the visit) is an insensitive measure, especially in comparison with direct observation and coding by trained reviewers of visit transcripts.3 Patient-reported request rates are higher still,4 in part because patients’ requests often use indirect linguistic forms that may be missed or misinterpreted by physicians.5 Third, a sample drawn from 3 tertiary care hospitals in Philadelphia hardly seems less selective than one drawn from primary care and cardiology practices in California. Finally, oncologists in tertiary centers already offer a full slate of aggressive diagnostic and therapeutic services. Few patients would have a need to request services that are already on offer.

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Article Information

Corresponding Author: Richard L. Kravitz, MD, MSPH, Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA 95817 (rlkravitz@ucdavis.edu).

Published Online: May 28, 2015. doi:10.1001/jamaoncol.2015.1105.

Conflict of Interest Disclosures: None reported.

References
1.
Gogineni  K, Shuman  KL, Chinn  D, Gabler  NB, Emanuel  EJ.  Patient demands and requests for cancer tests and treatments [published online February 12, 2015].  JAMA Oncol. doi:10.1001/jamaoncol.2014.197.Google Scholar
2.
Kravitz  RL, Bell  RA, Azari  R, Kelly-Reif  S, Krupat  E, Thom  DH.  Direct observation of requests for clinical services in office practice: what do patients want and do they get it?  Arch Intern Med. 2003;163(14):1673-1681.PubMedGoogle ScholarCrossref
3.
Bell  RA, Kravitz  RL. Direct observation and coding of patient-physician interactions. In: Whaley  BB, ed.  Research Methods in Health Communication: Principles and Application. New York, NY: Routledge; 2014:141-168.
4.
Kravitz  RL, Bell  RA, Azari  R, Krupat  E, Kelly-Reif  S, Thom  D.  Request fulfillment in office practice: antecedents and relationship to outcomes.  Med Care. 2002;40(1):38-51.PubMedGoogle ScholarCrossref
5.
Kravitz  RL, Bell  RA, Franz  CE.  A taxonomy of requests by patients (TORP): a new system for understanding clinical negotiation in office practice.  J Fam Pract. 1999;48(11):872-878.PubMedGoogle Scholar
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