The pressure to obtain better patient satisfaction scores can make it hard to say "no" to patients—but there are ways to make the conversation easier, Neil Chesanow writes for Medscape.

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"Straightforwardly telling a patient, 'No, you can't have that drug, test, study, or appointment,' maximizes the odds that the news will not go over well," Chesanow writes. Instead, he outlines 10 ways that providers can diplomatically tell their patients "no."

1. Explain why. Patients can get frustrated if they don't understand doctors' decisions. Providers need to explain how they formed their opinion and what course of treatment they recommend instead, which gives the patient a plan of action, Chesanow says.

2. Get to the root of the request. Providers need to understand why patients are requesting a certain drug or treatment. They may have seen an advertisement or heard from a friend that something is effective.

"It's debunking some of the stuff that they've heard or seen on TV," says Matthew Mintz, an associate professor of medicine at George Washington University School of Medicine.

3. Offer alternatives. "In general, when most patients ask for something specific, it's not that they 100% want that, it's just that they believe it's the right choice," says Mintz.

After providers explain why they're hesitant to provide what the patient requested, they should offer alternatives that are more in line with their best medical judgement, Chesanow advises.

4. Engage. Patients want to have a voice in their health care. By engaging them in the conversation and asking questions about their preferred care treatments, patients can feel like they've been heard, Chesanow says.

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5. Be positive. Even while delivering a "no," it can be helpful to play up positives, Chesanow notes. Describe to the patient all of the positive things he or she has done for their health, and how the requested treatment wouldn't help them continue on the same path, Chesanow advises.

6. Utilize clinical staff. Family physician Bradley Fox says he sometimes uses a "good cop, bad cop" routine with patients, in which the nurse will tell patients their request is unreasonable. "I'll walk in and say, 'Well, Carol seems to think that you're not happy because I won't prescribe the medication you requested. What's going on?' Fox says. "Now the conversation is open."

That opens up the conversation to discussing treatment options, Fox adds, making patients more likely to feel respected and respond.

7. Be empathetic. Patients don't just go to the doctor to get a prescription and leave. They want to know that their health concerns are acknowledged and understood. That feeling of dignity can be more important than a specific mediation.  

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"If I give a patient my undivided attention, and I sit down in the chair and meet them eye-to-eye and face-to-face and I listen, and then I give them my best advice, I think that counts as something," says John Mandrola, cardiac electrophysiologist at Baptist Medical Associates. "For the most part, listening and having empathy makes a difference in how patients respond to you."

8. Read your patient. The way providers deliver news should change based on the patient, physicians tell Medscape: their education level, preferences, and level of familiarity with the physician all should play a role as the physician works to align treatment with patients' goals.

9. Deflect the blame. If a patient isn't taking no for an answer, it can be helpful to explain that outside group hold some responsibility. "Specific guidelines are useful, particularly things that you can show people and say, 'That's why your insurance won't pay for it,'" says family physician Charles Davant.

10. Be firm. Despite taking the steps above, it can still be difficult for some patients to be told no. "You have to really be firm with certain people," says family physician William Sonneberg.

"At the end of the day, it's all about letting patients believe that they've at least won some dignity," Fox says. "The 'no' answer takes away their dignity. It takes away their feeling of self-worth and pride. You need to make them feel as though they still have that when they leave the office" (Chesanow, Medscape, 2/17).