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Review Question - QID 218791

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QID 218791 (Type "218791" in App Search)
A 22-year-old woman presents to a new primary care physician for evaluation of a 3-month history of increasing anxiety. She says that she has had problems with anxiety since she was a teenager but that her anxiety has skyrocketed after she graduated from college. She says that her previous doctor retired 1 year ago and she is presenting for evaluation because she ran out of her alprazolam. She says that she cannot function without it and feels like she is going to go crazy. When the physician asks her to provide additional history, she becomes very upset and says that he isn't taking her concerns seriously. She refuses to say more and asks whether he is going to prescribe her the medication and says that he would be heartless not to do so. Her temperature is 98.6°F (37°C), blood pressure is 116/71 mmHg, pulse is 95/min, and respirations are 18/min. A physical exam reveals a thin woman who is pacing around the room but is otherwise unrevealing. Which of the following is the most appropriate response to this patient's request?

"I am concerned that you may be developing substance use disorder."

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"I cannot prescribe you medication if you refuse to cooperate."

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"I need access to your records from your former physician."

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"I understand. Please tell me what dose of medication you have been taking."

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"I want to help you but need to have a full understanding of your history first."

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This patient who presents for initial evaluation and strongly requests a medication prescription should politely but firmly be asked to provide a history prior to fulfilling the request. An example statement would be "I want to help you but need to have a full understanding of your history first."

Physicians should respond to patient requests when they are appropriate; however, they should not feel pressured to accommodate unreasonable requests. When physicians are not comfortable with a patient request, they should first seek to better understand the circumstances surrounding the request by asking the patient to provide a history or further background information. In cases where physicians already have an established care relationship with a patient, they should also feel comfortable directing the patient back to the established treatment plan rather than make ad hoc adjustments unless urgent circumstances emerge. Physicians can accomplish this by politely but firmly setting boundaries.

Cam et al. studied the proportion of patients who have hospital visits due to inadequate medication-related follow-up. They found that 14% of patients had a hospital revisit within 6 months due to this problem. They recommended closer tracking of patient medications and refills in order to improve population health.

Incorrect Answers:
Answer 1: "I am concerned that you may be developing substance use disorder" is premature given that the physician has not yet obtained a full history and physical of the patient. Making this statement prematurely may adversely impact the patient relationship.

Answer 2: "I cannot prescribe you medication if you refuse to cooperate" is not the best answer. While physicians should not feel pressured to assent to inappropriate requests, physicians should voice these concerns in a polite but firm manner. This statement increases tension between the patient and the physician rather than ameliorating the situation.

Answer 3: "I need access to your records from your former physician" is not the best answer. While previous healthcare treatment records may be important in understanding the context of this patient's request, she is unlikely to agree to provide records at this time. It is more important for the physician to first politely but firmly ask for the patient to provide a full history.

Answer 4: "I understand. Please tell me what dose of medication you have been taking" is is not the best answer because physicians should not feel pressured to assent to patient requests before they have a full understanding of the situation. In this case, providing the medication would not be appropriate given the lack of an established treatment relationship.

Bullet Summary:
Physicians should not feel pressure to agree to inappropriate requests by patients.

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