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Clinical Take-Aways

  • Patients approach the clinical encounter hoping for an explanation for what is wrong, reassurance, advice on what to do, or a humanely delivered prognosis.

  • Each encounter is an opportunity for clinicians to set patients’ expectations anew.

  • Clinicians should:

    • Ask patients how they were hoping the clinician or clinic might help with their concerns.

    • Ask patients how they imagine any requested services might be helpful.

    • Try to focus on the patient’s underlying concerns, not (just) the specific request.

    • Be prepared to negotiate over services where the expected net benefits are marginal or negative.


Mr. A, a 32-year-old professor and running enthusiast, developed acute lower back pain while getting out of his car one Friday morning. Ibuprofen and bed rest over the weekend offered modest relief, but when the patient was seen on Monday, he continued to have moderate pain with activity, sometimes with radiation down the posterolateral aspect of the right thigh. Physical examination showed mild paraspinous muscle tenderness but no bony tenderness or neurologic findings. The patient’s gait was essentially unaffected. The preliminary impression was mechanical lower back pain accompanied by possible irritation of the S1 nerve root. Heat, analgesics, and progressive graded exercise were suggested, but the patient “couldn’t wait around” and insisted on having a magnetic resonance imagining (MRI) scan and evaluation by a spine specialist. A preauthorization request was initially rejected by the Accountable Care Organization (ACO), but Dr. M (his primary care physician) obtained permission to proceed after speaking with the ACO’s medical director. The MRI showed some facet arthropathy and a very mild lateral disc bulge at L5-S1. After reviewing the scan, the orthopedist prescribed heat, analgesics, and progressive graded exercise, and the patient improved rapidly over the next 4 weeks.

To talk sensibly about Mr. A’s story, we need to agree on terms. The academic literature has struggled to generate a common vocabulary for describing patients’ hopes, aspirations, goals, values, needs, wants, desires, expectancies, entitlements, requests, and demands. Our jumbled lexicon has arguably impeded research, teaching, and practice.

The first step towards definitional clarity is to distinguish between patients’ internal experiences and the way patients communicate (or elect not to communicate) with clinicians.1–3 On the verge of a clinical encounter, patients experience hopes and desires; these can take on shades of need (if the patient feels the object of desire is essential to their well-being) or entitlement (if the patient feels the object of desire is something they are owed as a matter of fairness). Requests are desires that are communicated to the clinician.

In our own research on patient-clinician communication, we have adopted the term patients’ expectations to refer broadly to the way patients think the clinical encounter should unfold. Like Brody et al. before us, we have tended to focus on perceptions of need or necessity, which ...

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