Physicians’ opinions on patients’ requests for specific treatments and examinations

Abstract

Objective  The number of technologies used in health care is growing, patients’ educational level has risen, health and drug information is increasingly available and patients today are actively looking for information from different sources. The aim of the study was to investigate physicians’ opinions on patients’ requests for specific treatments and examinations.

Design  The data were gathered as part of an annual physician's survey sent to all Finnish physicians (n = 16 698) by the Finnish Medical Association in March 2002. The response rate was 85% (n = 14 157). Physicians involved in clinical work were selected for this study (n = 12 255).

Results  Half (53%, n = 6521) of the clinicians reported either ‘very often’, or ‘often’ receiving requests from patients for specific treatments or examinations, and of them, 76% (n = 4972) reported an increase in such requests. The younger clinicians received more often patient requests. Women physicians, those working in health centres, and non‐specialized clinicians reported more experience of, and an increase in patients making requests. Of those clinicians who received patient requests ‘very often’ or ‘often’, 24% (n = 1595) considered such requests as having a positive, and 43% (n = 2808) a negative, effect on patient care and interaction; clinicians who did not receive many patient requests had similar opinions. Older, men, those working in private practice and specialized clinicians had a more positive attitude towards such requests than other clinicians. The reasons given for the positive and negative opinions were varied.

Conclusions  Active patients (consumer patients) are a reality in the Finnish health care system. Physicians have varying opinions on this phenomenon.

Introduction

The number of technologies used in health care is growing, the educational level of patients has risen, health and drug information is increasingly available and today's patients are actively looking for information from different sources. The empowered patients are potential consumers and their position in regard to the physician is more equal than before. Consumers challenge the traditional power relationship between patient and physician by emphasizing a physician's ‘obligations’ and the patient's ‘rights’.

The position of physicians with regard to empowered patients is not well studied. ¹ It has been reported that physicians are critical towards patients’ complaints, ² patients’ right legislation, ³ advertising of health care, ⁴ and direct‐to‐consumer advertising of prescription drugs. ⁵ In a study undertaken by Stevenson et al. ⁶ in England from 1996 to 1998, general practitioners were surprised that they should ask patients’ opinions, and questioned their ability to understand medical information, and presented this as a barrier to patient participation in the decision‐making process when it came to the matter of treatments. In Finland, observations and anecdotes suggest that, for example, many physicians have not followed this development, and ‘enlightened’ or empowered patients are seen as demanding patients.

Physicians have written critical essays on patients choosing a physician and/or a treatment, ⁷ , ⁸ but empiric literature on physicians’ perspectives is scant. In a study of Haug and Lavin ⁹ at the end of the 1970s in the United States, physicians were willing to abolish some measures of their authority and control, but only a few could accept patients’ demands for participation in decision making. Physicians’ opinions on patient requests for specific treatments or procedures have been studied in connection with euthanasia, ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ and in gynaecology and obstetrics, for example, with regard to birth procedures and abortions ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ (the latter being a field in which the health consumer movement made an early appearance ²⁰ , ²¹ ). In a study by Cohen et al. ²² involving 12 primary practices in Israel, patient requests for medical investigations were rare (2.4%), and one‐third of the physicians reported a negative feeling towards such requests. In a study in Finland in 1995, ²³ only 5% of the physicians wanted to be listed in a consumer brochure revealing their orientation on menopausal and postmenopausal treatment.

Patient requests influence physicians’ behaviour ²² , ²⁴ irrespective of their negative opinion of such requests. ²² The physicians’ decision to prescribe is influenced by both their perception of patient expectations ²⁵ , ²⁶ , ²⁷ and the feeling of being put under pressure by the patients. ²⁸

An influential approach in the current discussion on patient empowerment is to consider patients as consumers and assume democratic participation and equal partnership. This approach emphasizes shared decision making and patient‐centred care, ⁶ the physicians’ communication skills, ²⁹ patient decision aids, ³⁰ informed choice, ³¹ demanding patients, ³² and management. ³³ However, not all patients follow this negotiation model, but behave as real consumers shopping for services they think they need or deserve. This has been discussed especially in the US literature in connection with the services advertised directly to lay people.

The current literature on physician's opinions with regard to patient empowerment and consumerism focuses on specific medical procedures and fulfilling patient demands. We investigated the experiences and opinions of physicians as a whole on patients presenting requests for treatments and examinations. The issue was approached via the following questions: (i) Do physicians have patients who present requests for specific treatments and examinations? (ii) Has the number of patients who present such requests increased? (iii) What are the physicians’ opinions on patient requests?

Traditionally, patients’ rights have been regulated by various laws, but Finland was the first country in Europe to enact a separate law (Law on Patient's Position and Rights) in 1992 (forced 1993). The public health care system provides primary health care in health centres and specialized care in hospitals, and is funded through general taxation and administered locally through municipalities. The costs of using private practitioners are also partly reimbursed by the national sickness insurance. A physician may simultaneously practice both in the public and private sectors. The advertising of health services is defined and informally controlled by a professional body (the Finnish Medical Association). Physicians have clinical freedom, but deviant activities, through complaints, are controlled by a governmental body (the National Authority for Medico Legal Affairs), which has the right to restrict and abolish a physician's license to practice.

Methods

The data was gathered as part of an annual physician survey carried out by the Finnish Medical Association (FMA) in March 2002. The annual survey aims to update information on the physician's education, employment situation and contact information, but each year there is also a category of additional questions. This time, as a result of our proposal, they included questions about physicians’ experiences and opinions of patients who present requests for specific treatments and examinations, of the sharing of drug information with patients and consumers, and on the advertising of prescription drugs directly to consumers. In the cover letter, physicians were assured that their answers were not identifiable, and analyses would only be presented in anonymous format. The FMA sent the questionnaire to all non‐retired, working‐aged (<63 years old) physicians certified in Finland, with the exception of those who had given a total ban on mailing (n = 16 698). The response rate was 85% (n = 14 157).

The questionnaire was part of the FMA's annual survey, and because it was sent in the name of FMA, this may have influenced the high response rate. This, however, also resulted in restrictions for the study: only a few questions could be included.

Two specific questions sought to elicit the physicians’ experiences of patients who made requests for treatments. The first question was: ‘Do you have patients who, on arrival at their appointments, request specific treatments or examinations?’. The requests thereafter were specified as: (i) laboratory or other examinations, (ii) surgical or other procedures, and (iii) specific drugs. Each of the three items had four further options: ‘Very often’, ‘Often’, ‘Seldom’, ‘Very seldom’. We derived a new variable –‘report of patient requests in any of the items’– by combining the three items. The second question was: ‘Have the situations you indicated above increased during recent years?’ Again, this was further specified for the same three items as described above, with the options ‘Clearly’, ‘To some degree’, ‘They have not’, ‘I cannot say’. We derived a new variable –‘increase in patients making requests in any of the asked items’– by combining the three items.

To elicit the physicians’ opinions on situations where patient are making requests for specific treatments or examinations, we asked: ‘From the point of view of patient care and interaction, what is your view when the patients inform you on arriving at their appointment that they want to have specific treatments, examinations or drugs?’; with the options ‘Positive’, ‘Negative’, and ‘I cannot say’. Thereafter we asked an open‐ended question, ‘Please briefly explain your views?’. The data received from the open questions was coded by a trained research assistant using ATLAS.ti – program and qualitative content analysis through inductive category development (code hierarchy) was made. In the first step, sentence parts were isolated into basic units of analysis (codes or subcodes), and then in the second stage, the units were further conceptualized and connected to each other to form larger categories (upper codes, families). The reliability of the classifications in both stages was checked with one of the researchers (HT), and non‐replicable units of analysis and categories were modified.

We used Statistical Package for Social Scientists program (SPSS), and statistical testing of categorical variables was made using the Pearson chi‐square statistical package. In cross‐tabulations we used four age‐groups [≤29 years (n = 920), 30–39 years (n = 3485), 40–49 years (n = 4408), and ≥50 (n = 3435)], and included those over 59 years old to the preceding group because of their small number (n = 540). The physician's age turned out to be a strong confounding factor (see Results), and this was acknowledged in the analysis. To adjust for other background characteristics, we used three models of logistic regression: (i) age, sex and occupation; (ii) age, sex, and specialization; and (iii) age, sex, occupation and specialization. The age was a continuous variable and other background characteristics were categorical.

Respondents closely resembled the target group according to the studied background variables (age, gender, main occupation, specialization). ³⁴ Over half (54%, n = 6559) were women, 41% (n = 4992) had their main occupation in hospitals, and 59% (n = 7207) were specialized. This article will include respondents who did clinical work (n = 12 255, 87%). Their characteristics are given in Table 1.

Table 1.

Clinicians’ (n = 12 255) background characteristics by age

	≤29 (n = 920)	30–39 (n = 3485)	40–49 (n = 4408)	≥50 (n = 3435)	All	P‐value
Women1	66 (607)	66 (2301)	55 (2412)	36 (1239)	54 (6559)	<0.001
Main occupation2:
Hospital	45 (411)	48 (1677)	37 (1663)	36 (1241)	41 (4992)
Health centre	29 (268)	21 (737)	25 (1094)	20 (679)	23 (2778)
Private practice	0 (4)	4 (136)	13 (553)	16 (549)	10 (1242)
Other3	13 (118)	13 (456)	20 (869)	20 (678)	17 (2121)	<0.001
Specialization1:
Specialised	0 (0)	32 (1116)	73 (3228)	83 (2863)	59 (7207)	<0.001

¹ n = 12 248 (missing age information 7).

² n = 11 133 (missing main occupation information 1122).

³Includes education, administration and research, occupational health care.

P‐values refer to the differences between the age groups.

Values are given as% (n).

Results

Half of the clinicians (53%, n = 6521) reported as ‘very often’ or ‘often’ receiving patients who made requests for specific treatments or examinations on arrival at appointments. Laboratory or other examinations were the most commonly requested (Table 2).

Table 2.

Distribution of the clinicians by their reports on the frequency of patient requests for specific treatments or examinations

	Drugs	Surgical procedures	Laboratory examinations
Very often	3 (415)	2 (298)	6 (762)
Often	26 (3200)	21 (2512)	36 (4365)
Seldom	47 (5675)	43 (5365)	37 (4478)
Very seldom	15 (1844)	24 (2892)	13 (1620)
No information	9 (1121)	10 (1188)	8 (1030)
Total	100 (12 255)	100 (12 255)	100 (12 255)

Values are given as % (n).

Younger clinicians reported receiving patient requests more often than older clinicians (Table 3). However, adjustment for other background characteristics decreased this difference to some extent (Table 4). More men than women reported requests for surgical or other procedures, but more women than men reported requests for drugs and laboratory or other examinations. Those working in health centres reported requests mostly for laboratory or other examinations, while those working in private practice reported higher numbers of requests for drugs and fewer requests for other services when compared with those working in hospitals. Non‐specialized physicians reported requests of all kinds more than specialists, especially for laboratory or other examinations.

Table 3.

Proportion of clinicians who reported having ‘very often’ or ‘often’ patients who on arrival requested specific treatments or examinations, by age

	≤29 (n = 920)	30–39 (n = 3485)	40–49 (n = 4408)	≥50 (n = 3435)	All1 (n = 12 248)	P‐value2
Drugs	46 (426)	34 (1177)	28 (1252)	22 (760)	30 (3615)	<0.001
Surgical procedures	34 (314)	27 (928)	22 (956)	18 (612)	23 (2810)	<0.001
Laboratory examinations	68 (626)	47 (1643)	40 (1756)	32 (1102)	42 (5127)	<0.001

¹Missing age information 7.

²In testing differences by age groups, ‘very often/often’ groups in the distributions were tested against ‘very seldom/seldom’ groups, and ‘no information’ groups (8–10%) were excluded.

Values are given as % (n).

Table 4.

The likelihood of reporting patient requests ‘(very) often’ by clinicians’ background, adjusting for other background characteristics included in the model by logistic regression, odds ratios (95% confidence intervals) (n = 12 255)

	Model 11	Model 22	Model 33
Drugs
Age	0.97 (0.97–0.98)	0.99 (0.99–1.00)	0.98 (0.98–0.99)
Gender
Women	1.00	1.00	1.00
Men	0.78 (0.72–0.85)	0.76 (0.70–0.83)	0.79 (0.73–0.86)
Main occupation
Hospital	1.00	–	1.00
Health centre	2.35 (2.12–2.60)	–	2.12 (1.91–2.35)
Private practice	1.35 (1.16–1.57)	–	1.31 (1.13–1.53)
Other	1.73 (1.56–1.92)	–	1.64 (1.48–1.82)
Specialisation
Specialised	–	1.00	1.00
Non‐specialised	–	1.83 (1.66–2.01)	1.54 (1.40–1.70)
Surgical procedures
Age	0.98 (0.97–0.98)	0.98 (0.98–0.99)	0.98 (0.98–0.99)
Gender
Women	1.00	1.00	1.00
Men	1.14 (1.04–1.24)	1.15 (1.05–1.26)	1.15 (1.05–1.25)
Main occupation
Hospital	1.00	–	1.00
Health centre	1.58 (1.42–1.75)	–	1.50 (1.35–1.67)
Private practice	0.85 (0.72–1.00)	–	0.84 (0.71–0.99)
Other	0.62 (0.55–0.70)	–	0.60 (0.53–0.68)
Specialisation
Specialised	–	1.00	1.00
Non‐specialised	–	1.31 (1.18–1.45)	1.21 (1.09–1.35)
Laboratory examinations
Age	0.96 (0.96–0.97)	0.99 (0.99–0.99)	0.98 (0.98–0.99)
Gender
Women	1.00	1.00	1.00
Men	0.77 (0.71–0.84)	0.76 (0.71–0.83)	0.79 (0.72–0.86)
Main occupation
Hospital	1.00	–	1.00
Health centre	6.30 (5.65–7.03)	–	5.52 (4.94–6.17)
Private practice	0.85 (0.74–0.99)	–	0.82 (0.70–0.95)
Other	1.44 (1.31–1.59)	–	1.34 (1.21–1.48)
Specialisation
Specialised	–	1.00	1.00
Non‐specialised	–	2.43 (2.22–2.66)	1.80 (1.63–1.98)

¹The model includes age as a continuous variable, sex and occupation.

²The model includes age as a continuous variable, sex, and specialisation.

³The model includes age as a continuous variable, sex, occupation, and specialisation.

Clinicians reporting ‘(very) often’ patient requests were tested against the ‘(very) seldom’ groups.

‘No information’ groups were excluded in the analyses.

Of those physicians who reported receiving patient requests ‘very often’ or ‘often’, 76% (n = 4972) reported an increase in such requests during recent years [65% (n = 4209) for laboratory or other procedures, 57% (n = 3726) for drugs, and 48% (n = 3118) for surgical or other procedures]. With the exception of the youngest age group (≤29 years old), in which over one‐third (36%, n = 246) chose the ‘cannot say’ option [7% (n = 460) among all physicians], the differences between the different age groups were small. A reported increase in patient requests was found more in female than male physicians, more in non‐specialized than specialized physicians, and more so in those working in health centres than elsewhere. The increase in patient requests was experienced less in the private sector than in the hospitals.

The views of clinicians on patient requests were studied separately according to whether the clinicians received patient requests often or not. Of the clinicians who received patient requests (very) often, 43% (n = 2808) did not consider situations where patients requested specific treatments, examinations or drugs to be in the interests of patient care and interaction (Table 5). But, one‐fourth considered such a situation positive, and one‐third chose the ‘cannot say’ option or did not answer the question. The clinicians who received patient requests less frequently gave broadly similar opinions, with the exception of more ‘cannot say’ answers.

Table 5.

Distributions of clinicians (a) receiving patient requests ‘very often’ or ‘often’, and (b) receiving patient requests ‘seldom’ or ‘very seldom’, according to their opinions of the effect of patient requests on patient care and interaction, by age,% (n = 11 126)¹

	≤29 (n = 702)	30–39 (n = 2070)	40–49 (n = 2239)	≥50 (n = 1510)	Total (n = 6521)
Very often/often
Positive	10 (69)	18 (372)	28 (634)	35 (520)	24 (1595)
Negative	67 (469)	50 (1039)	37 (830)	31 (470)	43 (2808)
Cannot say	22 (151)	27 (560)	28 (634)	27 (407)	27 (1752)
No information	1 (13)	5 (99)	7 (141)	7 (113)	6 (366)

	(n = 188)	(n = 1151)	(n = 1800)	(n = 1466)	Total (n = 4605)
Very seldom/seldom
Positive	6 (12)	13 (147)	21 (376)	26 (374)	20 (909)
Negative	63 (118)	51 (588)	36 (642)	34 (502)	40 (1850)
Cannot say	27 (51)	31 (353)	34 (620)	33 (484)	33 (1508)
No information	4 (7)	5 (63)	9 (162)	7 (106)	7 (338)

¹No information of patient requests (n = 1129).

The differences in distributions by age were statistically significant (P < 0.001) in both groups; in testing, ‘no information’ groups were excluded.

Older clinicians had a more positive view of patient requests than younger clinicians (Table 5). The same was found among those clinicians who received less frequent patient requests. At the same time, the number of those choosing the ‘cannot say’ option rose from 22% (n = 151) to 33% (n = 484) among the older clinicians (Table 5). There was only a small difference according to gender or specialization; male and specialized clinicians were more likely to have a positive view than female and non‐specialized clinicians (Table 6). The physicians’ views on patient requests were the same, irrespective of whether they worked in hospitals or health centres. However, those working in private practice had a more positive opinion (Table 6).

Table 6.

The likelihood of reporting a positive opinion of patient requests by clinicians’ background, adjusting for other background characteristics included in the model by logistic regression, odds ratios (95% confidence intervals) (n = 12 255)

	Model 11	Model 22	Model 33
Age	1.04 (1.03–1.04)	1.04 (1.03–1.05)	1.03 (1.03–1.04)
Gender
Women	1.00	1.00	1.00
Men	1.16 (1.06–1.27)	1.10 (1.01–1.21)	1.15 (1.05–1.27)
Main occupation
Hospital	1.00	–	1.00
Health centre	1.00 (0.88–1.13)	–	1.05 (0.93–1.20)
Private practice	2.17 (1.88–2.52)	–	2.21 (1.91–2.56)
Other	1.48 (1.32–1.66)	–	1.52 (1.36–1.71)
Specialisation
Specialised	–	1.00	1.00
Non‐specialised	–	0.84 (0.75–0.93)	0.82 (0.73–0.92)

¹The model includes age as a continuous variable, sex and occupation.

²The model includes age as a continuous variable, sex and specialization.

³The model includes age as a continuous variable, sex occupation, and specialization.

Clinicians reporting a positive opinion on patient requests were tested against the ‘negative/cannot say’ group. The ‘no information’ group (13%) was excluded in the analysis.

Physicians gave many different reasons for their positive or negative opinions of patient requests, but the reasoning for most of the viewpoints centred around the same issues. The most common reasons for having a positive view were: (i) The patient is a subject participating in the treatment, and the treatment requires cooperation; (ii) The consultation and the interaction between physician and patient becomes easier; and (iii) The patient's knowledge is sufficient to enable requests, and that the requests are reasonable.

The most common reasons for having a negative view were: (i) The interaction between a patient and a physician becomes complicated, the roles are reversed, the consultation becomes difficult; (ii) The physician makes decisions on medical grounds and not based on patients’ demands; (iii) It is a threat to the profession and professionals; (iv) Patients’ medical knowledge is poor and requests are ill‐founded; (v) The requests drain resources (money, time, energy, expertise). Most of those physicians who chose the ‘cannot say’ option were of the opinion that it depends on the situation, or that patient requests do not influence them, or that their approach is ‘neutral’.

Discussion

Of the Finnish physicians involved in patient care, over half reported that they have patients who requested specific treatments, examinations or drugs, and of them most reported that there had been an increase in such requests. Requests for laboratory or other examinations were the ones received most often. Although many physicians had a negative view of such requests, this was not ambiguously so; many did not define their opinion or did not answer the question at all; while one‐fifth had a positive opinion. To consider patients as consumers is an established construction, especially in the American context and discussion. Our study indicates that more demanding consumer patients are a reality, and are also apparently an increasing phenomenon in the Finnish health care system, with physicians having a mostly negative or an uncertain attitude to this phenomenon.

There was some variation based on the physicians’ background. The experience of receiving patient requests, and an increase in the trend of the same, was more often reported by younger, women, non‐specialised, and those having main place of occupation in health centres, even after adjusting for background characteristics. They also had a more negative opinion of such requests. This corresponds with an earlier Finnish study ²³ that found older physicians and private practitioners have more positive attitudes than others towards a consumer perspective in health care.

The coverage of the study was good, as we benefited from being able to target all the Finnish physicians, with a subsequently high response rate. Our results do correspond with the findings of Kravitz et al. ²⁴ and Miller et al. ²⁵ The number of patient requests we found (53%) is broadly in line with results of Kravitz et al. (49%), ²⁴ although they used audiotape recordings. The exceptionally low rate of patient request (2.4%) in the study of Cohen et al. ²² may be explained by fact that the physicians were asked to complete a questionnaire after every visit in which a patient had requested a medical test over a seventh month period. In another study, Miller et al. ²⁶ also used physician questionnaires for each patient encounter related to a suspected infectious disease, although that study was over a 2‐day period.

Our results for the physicians’ opinions on patient requests are in line with the study of Cohen et al., ²² where both revealed that a third of physicians had negative feelings on patient requests. Many of those with a negative opinion argued in favour of the traditional authority and expertise associated with the medical profession. Moreover, many physicians made reference to limited resources, which is understandable in a system where only one‐tenth of the physicians work privately. Other studies have also reported that physicians perceive patients who come to the appointments with specific treatment requests as more demanding, ²⁴ time consuming ⁵ , ²⁴ and generally lacking in sufficient knowledge. ⁵ There is an increasing pressure on professionals to meet rising public expectations. ³⁵ Empowered patients take responsibility for their own health and some patients want to have full control over all medical decision making, ¹ even if it is against the physicians’ clinical judgement. ³⁶ Generally, especially in the US literature, there is the suggestion that the medical profession is facing significant changes in their position, autonomy and power because of the changing context in which they practice, including, proletarianization, ³⁷ , ³⁸ , ³⁹ deprofessionalization, ⁴⁰ and management ⁴¹ .

Our finding that the positive and negative views of physicians were both centred on the same issues illustrates the diversity and complexity in opinion on the question of patient requests. Many referred to the cooperation and interaction between the patient and physician, or to the level of patient knowledge in both arguments for and against. This may relate to the variety of communication skills required when working with demanding and requesting consumer patients.

The experience of receiving many patient requests is subjective and may in itself be a cause of negative feeling. On the contrary, prior negative feelings about the subject of patient requests may trigger the subjective experience of feeling there are an increased number of patients of this kind. Many younger physicians chose the option ‘cannot say’, which may be the result of them having less experience of clinical work. Less confidence in one's professional competence and self‐respect may also lead to reporting more patient requests and having a negative opinion of such. Older physicians, who have long work histories and much more clinical experience, reported less patient requests, but had a positive opinion of such. The reason for this may have been that patients found it easier to question a younger physician's authority and power.

Differences in experiences and opinions between female and male physicians may be explained by women's position in society: women do not enjoy the same authoritative position and prestige as men. It may be easier and more acceptable to present demands to a woman. Previous Finnish studies ⁴² of physicians’ opinions towards medical matters showed no differences between physician's opinions based on their gender. This supports the idea that it is patients who treat physicians differently according to the gender of the physician.

Physicians working in the public sector reported patient requests most often, while a more positive attitude towards such requests was present in the private sector. The reason for this finding could be payment incentives. In general, patients want to be sure that their problem is thoroughly examined. In the public sector in outpatient care, patients pay a fixed minimal consultation fee. They pay part of the drug costs, while examinations and surgeries are not paid for separately. Physicians have to prioritize treatments because of the limited resources provided by the state and the municipality. In the private sector, patients pay, in addition to the drug, also part of procedures and examinations themselves. Furthermore, patients probably do not think that physicians ‘skimp’ in prescribing drugs.

Secondly, the work conditions are different. Physicians working in public health centres are currently overloaded with work. In a study in South West England in 2000 ⁴³ it was also found that professionals who were working in primary care under pressure from internal changes had the most negative attitudes towards user involvement. Thirdly, expectations may vary. In the private sector, the physicians are ‘selling their services’, and ‘customers’ have more say than in the public sector, where roles are more even. ⁴⁴ , ⁴⁵

Our study relies on what physicians wrote in a very limited space, and to study what they really felt would require different methods to allow exploration in a greater depth. However, even this simple analysis suggests that recognition and views of patients’ requests deal with central issues in modern health care. It raises questions such as, who should decide what is appropriate, who should make resource allocation (prioritization) and how does financial incentives of physicians relate to expansion and costs of health care. Besides these health policy issues, patients expectations are in the centre of patients rights, and ask for defining the proper limits of subjective rights in health services.

In conclusion, we suggest that encounters with consumer patients must be considered when physicians are taught interaction skills, both in basic studies as well as in continuing education. Patients have a role in choosing their care, but their requests should not twist professional competence. Secondly, patients need education and decision aids to facilitate their participation in decision making during treatment. Thirdly, the public at large needs education on participation before they become patients. In this task, the media could have an important and central role. Resources are limited and the priorization discussion should be extended to the public so that they understand what priorization means concretely on an individual level (me vs. other patients). Finally, we need public discussion of these matters and cooperation between different health care actors.