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. Later that day, the physician discovers that the patient has questioned an office staff member about the physician's marital status. The following week, the patient calls and invites the physician to have dinner at a nearby restaurant. Which of the following is the most appropriate response?

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. Later that day, the physician discovers that the patient has questioned an office staff member about the physician's marital status.  The following week, the patient calls and invites the physician to have dinner at a nearby restaurant.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: The formal position of the American Medical Association is that any romantic relationship or sexual interaction between a physician and patient constitutes professional misconduct. Due to the inherent power structure of the relationship, sexual contact would allow for the potential exploitation of a patient or the clouding of a physician's judgment. It is expected that if a physician decides to enter a romantic or sexual relationship with a patient, he or she will at least terminate the physician-patient relationship beforehand. However, many ethicists argue that it is never appropriate to date a patient (even years after the physician-patient relationship has ended). (Choice A) This statement is inappropriate as it may encourage the patient to end the physician-patient relationship in the hope of being able to date the physician. (Choice C) This statement is critical of the patient and may be humiliating. It is better to explain that romantic relationships between physicians and patients are unethical. (Choice D) Although the invitation should be declined, it is inappropriate to refer the patient to another provider without discussing the issue first as the patient is likely to repeat the behavior. If the behavior continued despite discussion and the physician did not feel comfortable treating this patient, a referral to another provider could be made. (Choice E) Offering a polite excuse to spare the patient's feelings may be well intentioned but does not address the fundamental issue that dating a patient is a boundary violation. In addition, it implies that contact would be acceptable at another time. Educational objective: Sexual contact or a romantic relationship between a physician and a current patient is unethical. Many ethicists argue that this also applies to any romantic or sexual relationship with former patients. References: ACOG Committee Opinion No. 373: Sexual misconduct. (http://www.ncbi.nlm.nih.gov/pubmed/17666621)

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