A 35-year-old woman comes to the office for the third time in a month for follow-up. She called the office the night before reporting that her chest felt "tight" and was advised by the on-call physician to make an urgent office appointment today if she felt the need to be seen. The patient arrives an hour before her scheduled appointment and enjoys chatting with the office staff. She has a history of irritable bowel syndrome, dermatitis, anxiety, and mild asthma. Her record indicates that she has also called the office multiple times after hours to discuss various nonurgent matters, including questions about diet and hypoallergenic products. Today she is breathing normally and shows the physician a chart she has made documenting her asthma episodes and triggers. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 72/min, and respirations are 14/min. Examination shows no abnormalities. The patient says, "I didn't have time to show you this chart at our last appointment; the on-call doctor advised me to come in and show it to you." Which of the following is the best response to the patient's behavior?

Question

A 35-year-old woman comes to the office for the third time in a month for follow-up.  She called the office the night before reporting that her chest felt "tight" and was advised by the on-call physician to make an urgent office appointment today if she felt the need to be seen.  The patient arrives an hour before her scheduled appointment and enjoys chatting with the office staff.  She has a history of irritable bowel syndrome, dermatitis, anxiety, and mild asthma.  Her record indicates that she has also called the office multiple times after hours to discuss various nonurgent matters, including questions about diet and hypoallergenic products.  Today she is breathing normally and shows the physician a chart she has made documenting her asthma episodes and triggers.  Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 72/min, and respirations are 14/min.  Examination shows no abnormalities.  The patient says, "I didn't have time to show you this chart at our last appointment; the on-call doctor advised me to come in and show it to you."  Which of the following is the best response to the patient's behavior?

Quizplus · Accepted Answer

Explanation: This patient's frequent appointments and after-hours phone calls for nonurgent matters indicate a dependent behavior pattern. These patients are needy, and managing their demands for attention and reassurance can be challenging. The best approach is to be empathic and nonjudgmental but establish clear boundaries. The physician should explain what situations warrant an urgent call and direct the patient to other resources for guidance on routine questions. Making sure that all members of a treatment team are in agreement on maintaining clear boundaries with the patient can also be helpful. This can prevent staff burnout and minimize the potential for avoiding, or expressing anger toward, the patient. Excessively dependent patients may have underlying psychiatric problems (eg, anxiety, trauma-related and personality disorders) that require evaluation and treatment. However, this patient has not expressed psychological symptoms, and it would be premature to suggest a psychiatric evaluation (Choice C). Suggesting longer appointments is likely to be an impractical and temporary solution (Choice D); most dependent patients will still be needy regardless of appointment length. (Choice A) This statement may be perceived as dismissive and avoids the main issue, which is one of multiple phone calls and visits. If a limit regarding phone calls is not set, the pattern is likely to continue. (Choice E) This statement sets a limit but leaves it to the patient to interpret what is meant by a "true emergency." It would be more productive for the physician to explain what conditions and situations warrant immediate attention. Educational objective: Excessively needy patients who demand attention for nonurgent concerns are best managed by setting limits in a firm but empathic manner. Educating patients about specific guidelines for contacting the physician outside of office hours and providing alternate resources for routine questions are helpful strategies. References: Managing difficult encounters: understanding physician, patient, and situational factors. (http://www.ncbi.nlm.nih.gov/pubmed/23547575)

A 35-Year-Old Woman Comes to the Office for the Third