I don't refuse imaging. Comes of as dismissive or negligent if someone else orders and something shows up. Especially in our litigious society. Sometimes I will say something like:
"Happy to order but your insurance has strict criteria so you probably won't get approved and might get stuck with the bill".
Patients who push for procedures? Good problem to have. If you want to dissuade:
"Chances of success for this procedure, for your condition, are low, but happy to try".
"Happy to do it, but you don't fit the your insurance's criteria, and it can be expensive and there are potentially serious complications.."
"Every procedure has risks and benefits. If the potential benefits are low, as in your case, it's not worth the risks"
"We practice evidence based medicine, and there's not enough literature for me to be comfortable with that"
Patients with pathology but you can't fix:
"I've done all the procedures I know, maybe you could try another pain doc to get another set of eyes on you, or X,Y,Z".
"No treatment has 100% success rate" "Treatment failures happen, and while no one wants to think it'll be them, some will simply not respond"
Patients without much pathology:
"When I do procedures there has to be a target I'm trying to hit and there's no clear target on your MRI"
"I'm a spine specialist and my job is to see if your symptoms are from your spine, and based on your history, exam, and imaging, I can confidently say that your spine isn't the source. You might want to see..."
Opioids:
"With the opioid epidemic, there are strict guidelines we have to follow"
"The DEA frowns upon that, and I could lose my license, as other doctors have"
"We are a surgical and procedure based practice. We are not set up for chronic opioid management. State law requires drug tests, pill counts, etc, and we aren't set up to be able to adhere to those regulations, but other practices are [give options]"
"No one who gets addicted thinks they're going to get addicted. Your age puts you at high risk, so this isn't the best option"
You can see a few themes:
-come across as facilitative not obstructive
-blame insurance, guidelines
-patient needs to understand they have some skin in the game, especially financially and health wise