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"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."
"I need access to your records from your former physician."
"I understand. Please tell me what dose of medication you have been taking."
"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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