As a nation, we have come a long way in terms of patient care over the years. There was once a time when it was believed that patients lacked understanding of themselves, so they were assumed unable to participate in their own health care actively. As a result, paternalistic care was provided where a “provider knows best” approach was taken. Detailed explanations weren’t always given because it was assumed that because the provider said to do this or take this medication, there was no need to say more. The provider had made their decree!
Over the years, we have shifted to a better understanding that the patient brings valuable knowledge of their bodies to the table and thus should be a more active participant in their care. It seems, though, that we may have swung too far in the direction of thinking that the patient knows what is best for themselves.
As a result of this shift in perspective, sometimes patients enter treatment feeling entitled to specific medications. Some patients may feel entitled to receiving benzodiazepines for their anxiety or opioids to manage their pain. Against better judgment by the provider, these medications are prescribed, in part due to this culture shift in giving the patient what they want.
The business of medicine
There seems to have been a shift away from doing what is best for the patient and their long-term health towards satisfying “customers” that return to us. It’s important that patients are satisfied with their care, but at what cost?
Let’s look at what sometimes happens when a patient enters our office and immediately asks for a benzodiazepine to manage their sudden anxiety. The patient may be relentless in asking for the medication. We, as providers, may feel uncomfortable saying ‘no’, especially new nurse practitioner graduates, or we may feel too tired to say ‘no’ after seeing patient after patient all day. The easier response may be to say ‘yes’ and send the patient and their prescription on their way, leaving them satisfied at getting what they think they need.
When that patient with the benzodiazepine script returns next month for a refill, they might say the medication is working great to manage their anxiety, but they notice it is “not as good” as it first was. As a result, they want a higher dose, and to keep the patient satisfied, we might increase the dose. This cycle may continue for months or years on end, with the dosages slowing increasing. Over time, the patient becomes dependent on the benzodiazepine and needs the medication not to feel anxious. You, as the provider, worry that you have helped cultivate an addiction, so cut the patient off from the medication. Withdrawal rapidly occurs, which could be very dangerous for this patient who was suddenly taken off their benzodiazepines.
A patient demanding a medication and receiving it is one example of what can commonly occur in practice. When the business of health care is put at the forefront, the patient ultimately suffers. Our responsibility as providers is to put the patient’s health as the top priority in providing treatment.
When quality treatment is provided, patients return. Health care is not an industry that is going out of business anytime soon. Individuals are always in need of healthcare, whether preventative or curative. Patients ultimately need providers whose priorities are on their health.
We, as providers, know what is safe to prescribe, and the patient has experiential knowledge that is valuable as well. Together, the provider and patient can determine the best course of action for treatment. When we swing too far in either direction of “provider knows best” or “patient knows best,” problems develop. When patients feel they are not listened to or their considerations are not valued, they will stop sharing necessary information or not follow treatment. When the patient is fully in the driver’s seat, dangerous prescribing can occur. The key to quality treatment is working collaboratively with the patient.
Your rights as a nurse practitioner
Provider rights is a topic not talked about enough in school or practice. As a nurse practitioner, you have certain rights when providing care. You have a right to deny treating certain conditions. You have a right not to prescribe certain medications. You have a right to practice in a way that is ethical and maintains your integrity.
You do not have to treat every condition that you encounter. In fact, that could be considered negligent in some cases. For new graduates, in particular, if there are patients whose ailments are too complex, that you are unfamiliar with, or are outside your scope of practice, you do not need to treat these patients. At least not on your own and not right away. It’s much safer to understand when you are outside of your scope and seek assistance from an experienced provider or refer your patient to a more specialized or knowledgeable provider. You have this right as a provider.
You also have the right to refrain from prescribing medications you feel are inappropriate for a patient, even if they are demanding they have that medication. Holding back from prescribing despite a patient’s demands is one of the more complex aspects of your job. You have a degree, and the patient does not, which means that you have specialized knowledge the patient lacks. It is your responsibility to prescribe judiciously.
This can be difficult at times, especially when patients are very persistent, so it’s even more important to know you have the right not to prescribe or act in ways you deem unsafe or unethical.
You have more agency than you think, and when you become aware of this, everyone wins. Your patients are kept safe, and you feel more comfortable practicing ethically and with integrity.