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Clinical Take-Aways

  • The clinical encounter affords patients and clinicians the opportunity to influence each other—patients by what they reveal and request, clinicians by what they ask and recommend.

  • During a typical outpatient encounter, patients make requests for both information (e.g., about the significance of a symptom or lab result) and action (e.g., for medications, diagnostic tests, or referrals).

  • Patients whose requests for services are denied tend to be less satisfied with their care, less likely to recommend the clinician to a friend, and (for acute conditions) less likely to report symptom resolution at follow-up.

  • Clinicians are not obliged to accede to requests that are unreasonable, convey greater expected harms than benefits, or violate their own sense of professionalism. However, summarily rejecting a patient’s request will reliably diminish the patient’s care experience.

  • Clinicians should:

    • Give the patient an opportunity to lay out their full agenda at the beginning of the visit.

    • Talk less and listen more—try to pick up on why the patient is requesting a potentially inappropriate service.

    • Focus less on what patients ask for and more on why they are asking.

    • Be alert to patient cues and respond to patients’ emotions.

    • Be aware of their own emotional responses to patient requests.

    • When faced with a request for low-value care, consider substituting another service, stalling for time by offering a contingency plan, and providing clear instructions for reconnecting should the patient’s clinical condition fail to improve.


The United States spends more on health care than any other developed nation. Yet the United States does poorly compared to other advanced economies in terms of life expectancy, maternal mortality, and hospitalizations for diabetes and hypertension, among other outcomes (OECD 2018 health data). Since health care spending depends on the number of services provided (quantity) and the price of each service (price), health economists have scrutinized both factors, concluding that high prices explain most of the difference in health care spending between the United States and its peers. Nevertheless, these same experts have also concluded that up to a third of health care services are of little to no benefit to patients receiving them.1 Ironically, medical overuse occurs at the same time as medical underuse.2 Thus, the failures of our health care system might best be summarized as an allocation problem, or what Enthoven and Kronick have called “a paradox of excess and deprivation.” Some patients are overtreated at the same time that other patients (sometimes even the same patients) are undertreated. The result is scattershot quality of care and shameful health disparities.

While high prices need to be addressed (and there are plenty of health economists and policymakers working ardently to do so), misallocation seems like a more appropriate target for the clinicians and future clinicians reading this book. For one thing, allocation (and misallocation) of health care resources is largely under the control ...

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