A 35-year-old woman established primary care at a clinic 3 months ago. Last month, she arrived unannounced, urgently requesting to see the same physician. Due to a cancellation, she was seen later that day for the complaint of a rash on her chest. The male physician completed a thorough but unremarkable physical examination in the presence of a female nurse practitioner. Two weeks later, the patient comes to the same physician's office at closing time and without an appointment. She complains of "needing to talk to the doctor immediately about a private matter." She informs the receptionist that it is "absolutely critical" for her to be seen and examined for similar skin complaints that seem to "come and go" and "itch frequently." The patient is calm but insists that an appointment with the female nurse practitioner is not acceptable and instead requests to see the physician privately, without the presence of another staff member. Which of the following would be the most appropriate initial response by the physician?

Question

A 35-year-old woman established primary care at a clinic 3 months ago.  Last month, she arrived unannounced, urgently requesting to see the same physician.  Due to a cancellation, she was seen later that day for the complaint of a rash on her chest.  The male physician completed a thorough but unremarkable physical examination in the presence of a female nurse practitioner.  Two weeks later, the patient comes to the same physician's office at closing time and without an appointment.  She complains of "needing to talk to the doctor immediately about a private matter."  She informs the receptionist that it is "absolutely critical" for her to be seen and examined for similar skin complaints that seem to "come and go" and "itch frequently."  The patient is calm but insists that an appointment with the female nurse practitioner is not acceptable and instead requests to see the physician privately, without the presence of another staff member.  Which of the following would be the most appropriate initial response by the physician?

Quizplus · Accepted Answer

Explanation: This question addresses the importance of maintaining professional conduct when dealing with patients of all types, ranging from hostile to seductive. Several actions suggest that this patient could have boundary issues. These include: Arrival at unscheduled times and/or at closing time (when others are less likely to be available) Insistence on seeing the same physician for each visit (for mild conditions) and in private Frequent return visits for nonspecific complaints Health complaints that necessitate examination of private areas or undressing, despite recent normal findings To maintain a therapeutic distance, the physician should have the receptionist politely inform the woman that patients are seen only when they have scheduled appointments during normal office hours and with the presence of another staff member. (Choice A) Having an unscheduled appointment with the patient under these circumstances would only blur the doctor-patient relationship boundary. Instead, the physician should maintain a professional demeanor and discuss the patient's medical concerns during a scheduled appointment. (Choice B) Although the patient has inappropriate expectations, the situation does not appear to involve imminent concern for impending violence or escalation of her demands. Thus, contacting security is not likely to be necessary. (Choice D) The correct approach, even for seductive patients, is to provide the required medical care in a professional manner. This is not an emergency, so having the patient return for a scheduled visit, as opposed to telling her she is not to come back, would be appropriate. (Choice E) It is the end of the work day, and there is likely no need for the partner to take any immediate action. Thus, transferring care is not indicated. Educational objective: When dealing with difficult patients, the physician must maintain professional conduct and responsibilities while addressing their medical and psychological needs.

A 35-Year-Old Woman Established Primary Care at a Clinic 3