A 27-year-old woman with no medical history comes to the office due to recent-onset chest pain. She gives a dramatic, vague, and nonspecific description of the pain, which she continues even when pressed for details. The patient is dressed in revealing clothing and mentions having seen the physician several times at a nearby grocery store. Physical examination, including vital signs, is unremarkable. Laboratory evaluation and an ECG are normal and suggest no medical etiology for chest pain. Despite reassurance that more serious causes of chest pain are highly unlikely, the patient insists on scheduling a follow-up appointment. On the day of the second appointment, she arrives as the office is closing and intercepts the physician in the parking lot. The patient reports that the chest pain has disappeared; however, she is very concerned about feeling fatigued. She says, "I frequently have insomnia, but it's been worse than usual lately and I am so tired." The patient insists on calling the physician by first name, apologizes profusely for being late, and requests an after-hours appointment.
Which of the following is the most appropriate response to the patient's request?

Question

A 27-year-old woman with no medical history comes to the office due to recent-onset chest pain.  She gives a dramatic, vague, and nonspecific description of the pain, which she continues even when pressed for details.  The patient is dressed in revealing clothing and mentions having seen the physician several times at a nearby grocery store.  Physical examination, including vital signs, is unremarkable.  Laboratory evaluation and an ECG are normal and suggest no medical etiology for chest pain.  Despite reassurance that more serious causes of chest pain are highly unlikely, the patient insists on scheduling a follow-up appointment.  On the day of the second appointment, she arrives as the office is closing and intercepts the physician in the parking lot.  The patient reports that the chest pain has disappeared; however, she is very concerned about feeling fatigued.  She says, "I frequently have insomnia, but it's been worse than usual lately and I am so tired."  The patient insists on calling the physician by first name, apologizes profusely for being late, and requests an after-hours appointment. 
Which of the following is the most appropriate response to the patient's request?

Quizplus · Accepted Answer

Explanation: Patients with poor interpersonal boundaries tend to elicit strong reactions from their physicians. Proper management and diagnosis of medical and psychiatric disorders of these patients can be challenging and require patience and insight on the behalf of the physician. The best response to the patient's seductive behavior, inappropriate familiarity, and request for special treatment is to calmly set limits and establish clear professional boundaries. This allows for appropriate medical treatment and the maintenance of a professional physician-patient relationship. If a patient in stable condition insists on being examined outside of office hours, it is best to maintain a pleasant but firm stance by instructing the patient to reschedule an appointment during normal business hours. (Choice A) Referring the patient to a colleague who has no knowledge of the patient would not be optimal and encourages the patient's inappropriate demands for special and immediate attention. It is better to schedule a regular appointment, during which the same physician can perform the assessment. (Choice B) Referring the patient to the emergency department for a nonurgent condition is inappropriate and contributes to the problem of emergency department overuse. (Choice C) Performing an examination in the office despite the late hour is inappropriate; this reinforces the patient's sense of entitlement and poor boundaries by accommodating an unreasonable request. A stable patient who fails to arrive at the appointed time should be advised to reschedule the appointment. (Choice D) Although this statement sets a limit, its overly judgmental tone can be damaging to the physician-patient relationship. Educational objective: When a patient behaves seductively and makes inappropriate requests, the best response is to calmly set limits and establish firm boundaries to maintain the professional physician-patient relationship. References: Boundaries in the doctor-patient relationship. (http://www.ncbi.nlm.nih.gov/pubmed/12467344)

A 27-Year-Old Woman with No Medical History Comes to the Office