Business Dilemmas

Dr Kathryn Leask gives some useful detailed advice in response to a consultant’s query about appropriate action to take if a patient becomes abusive.

 

             

         

           

Dilemma 1

Can I refuse to treat patient?

Q I had a very unpleasant private consultation with an intimidating and verbally aggressive patient who was referred to me with a frozen shoulder. 

He raised his voice to my receptionist when she told him my previous consultation had overrun by a few minutes and refused to wear a mask in the waiting room, which made other patients uncomfortable. 

During the consultation, he swore loudly at me when he felt some pain during my physical examination, although I had warned him that it might hurt. 

Then he became angry when we discussed treatment options, after I recommended a course of steroid injections and physiotherapy, shouting that he had been in pain throughout lockdown and wanted surgery. 

He then said he would think it over and has just emailed to request another appointment, but I really do not wish to see him again. We have a zero-tolerance policy on abuse, so can I simply refuse? 

A There is evidence that doctors have experienced an increase in abuse from patients. 

Two-thirds (66%) of the 418 doctors who responded to an MDU survey said levels of abuse from patients and their representatives had increased and nearly half of doctors surveyed (49%) identified waiting times for treatment as the main reasons for patients and their relatives to become abusive.

Of course, this patient’s ongoing pain and frustration about the delay in accessing specialist care had a bearing on his actions, but that does not mean you have to tolerate aggression. 

The challenge is how to respond effectively to poor behaviour, without aggravating the situation or treating the patient unfairly. 

As an independent practitioner, you have more freedom to decide who you will accept as a patient. However, you have already seen this man for an initial consultation and, from his perspective, you have agreed to treat his condition and established a professional relationship. 

Breakdown of trust

With this in mind, you need to be aware of GMC guidance which says you ‘should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient’ and that you ‘must be satisfied that your reason for wanting to end the relationship is fair and does not discriminate against the patient’. 

Simply refusing to see the patient again without any warning or any attempt to restore your professional relationship is contrary to GMC guidelines and could aggravate the situation. It would also be hard to justify if the patient decides to make a complaint.  

Instead, this is the moment to warn the patient that his behaviour during his first consultation was unacceptable and give them the opportunity to change. 

You could set out your concerns in your response to his email and point to your practice’s zero tolerance policy and the consequences if he continues to swear or upset staff. 

Your practice’s policy

You could also clarify your practice’s policy on mask wearing and why, at the time of writing, the Government still recommends face coverings in indoor spaces, particularly healthcare settings. 

If the patient can’t wear a mask for any reason, this will be resp­ected, but you will need to take steps to minimise the risk for other patients.   

Hopefully, the patient will apologise and change his behaviour, but he may decide that he does not want to attend your practice. But if his behaviour continues to cause concern, it would be reasonable to end the professional relationship. 

In doing so, the GMC says you need to tell the patient your reasons, in writing and record this in their records, ensuring you ‘do not include anything that could unfairly prejudice [their] future treatment’. 

Finally, with the patient’s consent, you should ensure suitable arrangements are made promptly for his continued care and you pass on his records without delay. 

Dr Kathryn Leask is a medico-legal adviser at the Medical Defence Union

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Patient refuses a chaperone

Dr Sally Old explains how you should respond if an insistent patient refuses a chaperone

 

 

 

 

 

Dilemma 2

Do I acceed to patient’s wish? 

Q I’m a male, private GP who recently saw a 15-year-old girl, attending alone without her family who are regular patients of mine. 

She explained she was very worried because, in the shower a few days ago, she thought she had felt a breast lump. She was tearful and anxious. She had not told anybody else about this and was very worried because her maternal grandmother had died in her 60s of breast cancer.

The patient was clearly very upset but was keen to be examined there and then. 

I explained that I would like to discuss the matter further with her and that if I were to proceed with a breast examination then I would like to have a chaperone present.

The patient became very distressed and said she did not wish anyone else to be present and wanted the examination to take place as soon as possible. 

Could you advise on how I should have proceeded? 

A A chaperone is defined as an independent observer present during an intimate examination of a patient. 

They are usually a health professional who is familiar with the procedures involved in the examination and can offer the patient reassurance and support. 

The chaperone will usually, but not always, be the same gender as the patient.

The GMC’s guidance, Intimate examinations and chaperones (2013), states that doctors should offer the patient the option of a chaperone wherever possible before conducting an intimate examination, whether or not they are the same gender as the patient. 

Although a chaperone should be a trained health professional, doctors should comply with ‘a reasonable request’ to have a family member or friend present alongside the chaperone.

Chance to ask questions

The GMC guidance also highlights that, before conducting an intimate examination, a doctor should give the patient a clear idea of what to expect. Explain why the examination is necessary, and what it will involve, in a way the patient can understand. Give the patient a chance to ask questions. 

When dealing with a child or young person, you must assess their capacity to consent to the examination. 

If they lack the capacity to consent, you should seek their parent’s authority.

Patients do have the right to refuse a chaperone. However, if you are uncomfortable with undertaking an intimate examination without a chaperone, you should explain why you would prefer to have one present. 

You may be able to offer an alternative chaperone, or an alternative doctor, if the patient’s clinical needs allow.

You should document your discussion about the examination and chaperone in the clinical record.  

Moving forwards, consider publicising your chaperone policy so that patients know the service is available and they are encouraged to make their wishes known at an early stage.

Dr Sally Old is a medico-legal adviser at the Medical Defence Union

• See ‘Your duty to own up’