Boundaries

On a more philosophical note today, I recently had a very uncomfortable experience with the mother of a young patient. The patient was 16 and presented to my office complaining of heavy and painful periods. She was missing school because she leaked through her pads in class and was afraid it would happen again. Her mother kept her home 2-3 days before her period, and during her period, so she was missing about 8 days of school per month. I’ll spare you the details, but the eventual diagnosis was dysmenorrhea and suspected PCOS. I started her on low-dose OCPs, with ibuprofen and tylenol for the pain, and scheduled her for follow-up in a few months. I also told her to go back to school, and to make sure to change her pads regularly to decrease the risk of soaking through her clothes at school.

A week later I got a note from our clinic’s phone nurse that the patient’s mother had called. The patient hadn’t been back to school since she saw me. She wanted a doctor’s note excusing the patient from school, and a prescription for narcotic pain medication for the patient’s cramps. Cue ominous music…

So, how do you deal with these sorts of patient requests? It’s important to me to maintain a doctor-patient relationship, but I’m also not willing to start a 16-year-old on narcotics a chronic issue, or to write her out of school for a quarter of the school days of each month.

It gets into a few bigger issues, though. For example, who am I to decide how much pain is too much pain? It doesn’t seem fair that she tells me she has pain that isn’t controlled with tylenol and motrin, and I say “That’s nice, but I’m not giving you anything stronger.” On the other hand, it seems equally absurd to start a teenager on an addictive narcotic medication for one week out of every four.

I called the patient’s mother back and explained to her that I was in a difficult position. I told her that I really wanted her daughter to feel better, but that when I saw her in the office they didn’t say anything about needing a school note. Based on what I saw in the office, I recommended that the patient go back to school, and I felt very uncomfortable being asked for a note after the fact without examining her again. I understood that there may have been a miscommunication so I was willing to write a note this once, but I wasn’t going to be writing any further notes for missing school for period cramps and bleeding over the phone. If she was having severe pain, she needed to be seen in the emergency room or as an urgent work-in in the clinic.

In the end, everyone came away happy. I felt like I was taking care of my patient without compromising my ethics. The patient’s mother felt like I was taking care of her daughter, and understood that I wanted to do what was best for the patient, instead of just doing what I was asked.

I’m seeing her back for a follow-up visit in a few weeks, so I guess we’ll see how things go when I see them next.

In the meantime, here are my tips on dealing with these situations:

• Set boundaries. Decide what you are willing to compromise on. For me, I was willing to write her a note excusing her for the days she had missed since her appointment with me, on the assumption that it was a misunderstaning. I was not willing to excuse her from any more school after the day of the phone call.
• Open with the things you are willing to do, before you talk about the things you aren’t willing to do.
• Have a good reason why you won’t do the things you aren’t willing to do. For example, this patient’s mother was asking about tramadol – she didn’t think of it as a narcotic. I explained to her that tramadol is a narcotic, and that the FDA issued a warning against use of tramadol in minors. That was enough for her.
• If necessary, appeal to authority (not your own). I looked up treatment guidelines for dysmenorrhea, and confirmed that none of the major OB/GYN organizations recommend narcotics as part of the treatment for dysmenorrhea, and in fact several caution against it.

So, how do you deal with patients asking for things you aren’t comfortable giving them?