Dilemmas

Working as a GP your skills may be called upon when you least expect it. Dr Richard Stacey, MPS medicolegal adviser, gives advice on how to deal with tricky situations

Dilemma 1. Poor-performing colleagues

You’ve started locuming at a large practice. During afternoon surgery you see a 30-year-old patient who saw their usual GP a fortnight ago. The patient is complaining of the same symptoms she described on her first visit.

Upon examination, you make a different, “obvious” diagnosis. Surprised that the other GP missed it, you garble: “Dr Evans should have seen that. I can’t believe he missed it”. You have criticised your colleague in front of a patient. Is this ever okay to do?

A medicolegal opinion

MPS commonly sees complaints or claims that have been instigated by a patient only after another clinician made a comment. In most cases, it’s not that the doctor has advised the patient to pursue a claim or complaint, but that they have made a comment that has been construed by the patient as criticism, snowballing into an official claim or complaint. So it is important to be careful with regards to what you say, bear in mind that you were not party to the consultation and the symptoms may have evolved in the intervening period.

The GMC advises:

• When working in a team, you must respect the skills and contributions of your colleagues. 
• You must treat your colleagues fairly and with respect, and not unfairly discriminate against them by allowing personal views to affect your professional relationship with them. 
• You must not undermine patients’ trust in their care, or in the judgment of those treating them, by making unfounded and malicious criticisms.

Raising concerns about a colleague’s performance as a locum can be tricky, especially if the doctor in question is employing you. However, the GMC is clear. If you do have serious concerns about a colleague’s fitness to practise you should not keep it to yourself, as the safety of patients must come first at all times.

If you have concerns, an honest explanation should be given to your contracting body, or an appropriate person locally – PCT, medical director, responsible officer, etc. These bodies will have procedures in place to deal with accusations of this kind.

Dilemma 2. Medical requests outside the surgery

You’re walking your children to the school gates, when Mrs Jones, accompanied by her twin boys Peter and Simon, stop to say hello. You’re quite friendly with Mrs Jones and have treated her children over the years while locuming at the local practice.

You begin a general conversation with her. She begins discussing her sons and says: “It’s quite coincidental that I’ve seen you actually, because I was going to book an appointment with a doctor as soon as I got home. Will you save me the bother?” She goes on to describe the symptoms of a recurring problem Peter is experiencing.

Do you listen attentively and share your medical opinion?

A medicolegal opinion

Initially you may be happy to give someone general advice about a problem; however, it is worth bearing in mind that to do so might engender a claim if something went wrong.

The GMC does not offer advice on dealing with informal consultations. However, there are some general questions to consider: 

• Can you deliver good clinical care, by adequately assessing the conditions, examining the patient and taking account of a full history? 
• Can you fully assess a patient in this context, ie, examine them, take a full history, in a public setting? 
• Can you arrange further investigations or treatment where necessary? 
• Can you refer the patient to another practitioner for follow-up? 
• Can you record your findings in the medical records?

Doctor–patient relationships are effective because a professional boundary exists between doctor and patient. Discussing a general problem outside surgery may breach this boundary and undermine the trust that is so crucial to the relationship. In the case of Mrs Jones, you should adopt an empathic approach and explain why it would be better for her to make that appointment and see a GP at the surgery.

Stress that you would not be able to properly diagnose her son’s condition without being able to review his medical notes or conduct the necessary examination or tests. If she persists, add that to offer advice with incomplete information may cause a serious problem to be missed.

Dilemma 3. Requests for references

An acquaintance, who you have also seen as a patient at another surgery, sees you when you’re shopping in town. He asks if you could write him a character reference for a new job. Although as an acquaintance you would have no qualms about doing this, as a GP, you are aware of his previous history of depression. What do you do?

A medicolegal opinion

In this dilemma the problems encountered would be similar to those in Dilemma 2. How do you manage an informal consultation? You may not see a problem with writing the reference, and may be happy to do it, but if something went wrong you would be liable.

In this dilemma you are in an awkward position. It would be best to explain that, as you have seen him in surgery, you would not be the best person to provide a reference of the type he is requesting.