When your patient doesn’t want a diagnostic test

What can you do when your patient refuses a diagnostic test? It depends. As I’ve said before, there is value in assessment and individualization.

For example, a 51 year old woman reported months of having vertigo. Her doctor told her if the medicine he gives her does not work, he will send her for an MRI to look for the source. The medicine didn’t work, but she did not return to the doctor. She told herself it was just vertigo, she did not want to be sick enough to need a doctor, she did not want to have an MRI because it might find something, and she was scared.

A month later her husband brought her to the Emergency Room because she could not balance and had nystagmus. Their MRI found a tumor in her left cerebellum, which appeared to be restricting the flow of cerebral spinal fluid. The next day she had brain surgery.

Many people refuse to have diagnostic tests out of fear. Some understand what the test would show, but don’t understand the potential consequences of not having the test. Some will not tell their health care professionals they choose not to have the test, just like they may not reveal they have no intention of filling a prescription. It is easier to not follow through than to have that conversation.

It is easy for a busy health care professional to think his or her obligation is done when the rationale for the test is explained and the order is written. However, providing quality health care is just as much about relationships as it is technical knowledge and skill.

What could you have done if you were the health care professional seeing this woman? When telling her why you would send her for an MRI if the medicine doesn’t help, your assessment of her emotional response can cue you into resistance, anxiety, or fear. A few questions about what she is thinking might reveal her point of view. That could give you an opportunity to explain the potential consequences of not having the test.

Although you cannot make a competent adult do something, you do have the capacity to influence self-care behavior. The first level of patient education is information transfer. The second level is helping the patient apply this new information to life. This process is called health coaching, which incorporates skills in listening, collaborative goal setting, motivational interviewing, and facilitating behavior change. Once you identify the patient’s goal (emotional self-protection) is different from yours (accurate diagnosis), you know how to introduce the conversation and can openly discuss it to find a common ground. This is where you individualize your approach.  Some of Arthur Kleinman’s classic questions may help you better understand the patient’s point of view. Only ask the questions that are appropriate in the situation.

What do you think caused the problem?
Why do you think it happened when it did?
What do you think your sickness does to you? How does it work?
How severe is your sickness? Will it have a short course?
What kind of treatment do you think you should receive?
What are the most important results you hope to receive from this treatment?
What are the chief problems your sickness has caused for you?
What do you fear most about your sickness?

Ask with interest in the person, without judgment, interruption, or correction.  This process will not just provide you with information about the patient’s point of view, it will facilitate collaborative goal setting, and build your therapeutic relationship. Without this conversation, the patient may just refuse the diagnostic test. With this conversation, you have a chance at improving the health outcome. And isn’t that the point?

Source: Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258.

©2017 Fran London, MS, RN

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