A 46-year-old woman comes to the office for evaluation of chronic fatigue, dizziness, itchy skin, and headache. She says, "I can barely clean the house anymore. I get so tired, and every cleaner I use makes me break out in a rash." The patient's symptoms began 3 years ago when her home was remodeled and she was exposed to various chemicals. Exposure to even small amounts of smoke or perfume significantly exacerbates her symptoms. The patient has a history of depression, tension headaches, and hypothyroidism treated with levothyroxine. She does not use tobacco, alcohol, or illicit drugs and follows an organic, vegetarian diet. She previously worked as a lawyer but has stopped due to her symptoms. During the visit, she pulls out a large folder with several Internet articles on multiple chemical sensitivity syndrome and insists that the physician read them. She says the last 2 doctors she consulted were "totally incompetent" and that "if you know anything at all about medicine, you must know that environmental challenge testing is needed to confirm my diagnosis." Which of the following is the most appropriate response to the patient's request?

Question

A 46-year-old woman comes to the office for evaluation of chronic fatigue, dizziness, itchy skin, and headache.  She says, "I can barely clean the house anymore.  I get so tired, and every cleaner I use makes me break out in a rash."  The patient's symptoms began 3 years ago when her home was remodeled and she was exposed to various chemicals.  Exposure to even small amounts of smoke or perfume significantly exacerbates her symptoms.  The patient has a history of depression, tension headaches, and hypothyroidism treated with levothyroxine.  She does not use tobacco, alcohol, or illicit drugs and follows an organic, vegetarian diet.  She previously worked as a lawyer but has stopped due to her symptoms.  During the visit, she pulls out a large folder with several Internet articles on multiple chemical sensitivity syndrome and insists that the physician read them.  She says the last 2 doctors she consulted were "totally incompetent" and that "if you know anything at all about medicine, you must know that environmental challenge testing is needed to confirm my diagnosis."  Which of the following is the most appropriate response to the patient's request?

Quizplus · Accepted Answer

Explanation: This patient's conviction that she suffers from multiple chemical sensitivity syndrome and her demand for testing present a challenging situation for the physician. Such patients will often perform extensive Internet searches to support their health beliefs and present the physician with articles. The situation is often compounded by patients' anger and frustration with previous providers who have minimized or invalidated their concerns. The most appropriate response is to validate the patient's symptoms and establish an effective physician-patient relationship. Immediately rejecting the patient's request is likely to increase her frustration. Complying with the patient's demands or disputing the scientific validity of her concerns should also be avoided. Obtaining further history, performing a physical examination, and ordering basic laboratory testing (including thyroid function tests) convey that the physician cares and takes the patient's symptoms seriously. At the same time, this approach avoids unnecessary, unproven, and expensive testing. Many patients who believe that they have multiple chemical sensitivity syndrome have underlying depressive, anxiety, or somatic symptom disorders. Although a psychiatric history should be part of the evaluation, focusing on psychological issues may be perceived as invalidating the patient's physical distress and is likely to impair the physician-patient relationship at this early stage (Choice C). (Choices A and B) These statements, by challenging the patient and dismissing her request, will likely anger her and impair the physician-patient relationship. Once a relationship is established, the physician's explanation of recommended workup and treatment is more likely to be accepted. (Choice E) Complying with the patient's demand for unnecessary testing is inappropriate. The physician should acknowledge the patient's distress and recommend an appropriate initial workup. Educational objective: Initial encounters with demanding patients are best managed with a nonjudgmental, empathic approach that validates their concerns. Obtaining further history, performing a basic laboratory workup, and building a doctor-patient relationship should take priority; unnecessary diagnostic testing should be avoided. References: Managing difficult encounters: understanding physician, patient, and situational factors. (http://www.ncbi.nlm.nih.gov/pubmed/23547575) Chemical intolerance. (http://www.ncbi.nlm.nih.gov/pubmed/26088215)

A 46-Year-Old Woman Comes to the Office for Evaluation of Chronic