‘Business Dilemmas’

Sally Old 4 webWhile dealing with an ethical dilemma, doctors should also take into account how their actions might affect a vulnerable patient. MDU medico-legal adviser Dr Sally Old (right) considers two private practice scenarios involving patients who have been diagnosed with cancer

Dilemma 1

A missed opportunity

A designer in his 40s came to see me because he was concerned about a mole on his shoulder that had been bleeding.

He had seen his GP the previous month, who told him that this was probably due to his rucksack rubbing on his shoulder but he had not been reassured and self-referred to me for a second opinion.

On examination, the mole was asymmetric with a raised border and patchy in colour. Histology later confirmed that it was a malignant melanoma.

I’m worried that the GP could have overlooked such obvious symptoms. It’s a particular concern because the same practice referred another patient last year with a suspected melanoma but only after she had returned to her GP several times.

[quote]What action should I take and should I raise a concern about this practice? Should I tell my patient to make a complaint?[/quote]



It is understandable that you feel troubled about this and of course all doctors have a duty to raise concerns if they feel patient safety is being compromised.

In the first instance, you could write to the practice, explaining that you wanted to notify them of the diagnosis, and diplomatically explain your concern that this diagnosis could have been missed.

Make sure you ask them for a response as you have a responsibility to ensure that your concern has been addressed appropriately and keep a record of your concerns and the action you have taken.

The practice should have a process for investigating adverse incidents and learning lessons from what went wrong. In this case, you might expect them to carry out a root cause analysis of the incident and if necessary an audit of the dermatology cases to confirm that no other patients need to be called back for review.

The doctor involved might also need to undertake some additional CPD in relation to dermatology. Finally, the practice would be usually be expected to notify the Care Quality Commission about any incident that led to the shortening of a patient’s life-expectancy.

If you are satisfied with the practice’s response, it would be reasonable to leave the matter for them to manage. If however you receive no response, or an unsatisfactory one and you remain concerned, then you could write to the NHS England Local Area Team who have the power to investigate these concerns and take action if they deem it necessary.

You also have a duty to be open and honest with your patient but bear in mind you do not yet have all the facts. It is likely he will already be angry and distressed that an earlier opportunity to make a diagnosis was missed.

If this is the case, it might be reasonable to suggest that he raises his concerns directly with the practice.

However, it is important that the patient does not feel the responsibility lies entirely with him so explain that you are going to write to his GP practice yourself about his diagnosis and ask for his consent. You might also want to offer the patient the chance to speak to a counsellor.


Stressful people waiting for job interview

Dilemma 2

Chaperone distress

I am treating a woman with metastatic lung cancer. She has just called me to arrange an appointment after returning from a business trip because she has been experiencing back pain and her foot drags when walking.

I suspect she may have cauda equina syndrome and explained that I might need to carry out a rectal examination to be sure.

After an incident with an amorous patient a few years ago, it’s my usual practice to insist on a chaperone for all intimate examinations but the patient has now told me that she doesn’t like having someone else in the room.

[quote]Should I go ahead with the examination without a chaperone, despite my misgivings?[/quote]



Your patient’s refusal of a chaperone should be respected but clearly it leaves you in an uncomfortable position, especially given your past experience of a patient behaving in a sexualised way.

You could try explaining to the patient why you want a chaperone present although it is important that you broach the subject sensitively so she does not feel pressurised into something that she would not otherwise have chosen.

However, ultimately you need to prioritise her clinical needs over your own feelings. Bear in mind that the patient might require urgent referral for an MRI scan so any delay would almost certainly adversely affect her health and comfort. This means it would probably not be appropriate to refer the patient to a colleague who would be prepared to proceed without a chaperone.

If you carry out the examination, make a careful record of your reasons and note that a chaperone was offered and declined.

Finally, if your practice does not already have a chaperone policy, it is a good idea to produce one for your website or practice literature. This will help to manage patients’ expectations and may make it easier to meet their needs.