Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Saying No With Compassion And Curiosity


When patients request something that is unsafe, be curious and explore their perspective before declining. This approach is collaborative and less stressful for both clinician and patient. 

Recently, a colleague approached me to vent about a frustrating patient encounter. She described a woman in her mid-80s who was requesting a benzodiazepine as a sleep aid. The conversation went something like this: 


Patient: I’d like a prescription for Valium to help me sleep. 


Physician: Well, I’m not comfortable prescribing that type of medication for sleep. There are some worrisome side effects. 


Patient: But my friend uses it, and she has the same health issues that I have. 


Physician: Well, that’s nice, but I’m not comfortable prescribing it for you. 


After the patient’s final retort of, “You younger doctors are just so difficult about some things,” they were able to move on to other matters. Both physician and patient were unsatisfied. 


Later, I thought about how this conversation might have gone better. Perhaps if my colleague was less defensive, they may have found their way to the same conclusion in a more mutually agreeable way. The conversation might have gone like this: 


Patient: I’d like some Valium to help me sleep. 


Physician: Hmm . . . What have you heard about Valium as a sleep aid? 


Patient: Well, I hear it helps relax you so you can get to sleep. 


Physician: May I ask where you found your information on Valium? 


Patient: I have a friend who uses it. She’s my age and has similar health problems. 


Physician: Oh, I see. Have you heard about any of the risks of taking Valium? 


Patient: There are risks? 


Here the physician shows curiosity about the patient’s source of information and stimulates the patient’s own curiosity about risk. This exchange feels more collaborative; declining the request then comes across as thoughtful and in the patient’s best interest. 


When a patient makes a request that you feel is unsafe: 


1. Be curious about the request.


2. Ask open-ended questions that allow the patient to explain his/her/their perspective and its origin.


3. Explore risks of the request together before making a recommendation.








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.