Understand what your patient wants
What can you do if a patient is unsatisfied with the outcome of their consultation and refuses to pay? Fin Wright discusses some steps you could take.
It can be frustrating for a private doctor when, after seeing a patient and writing a report detailing the consultation and your findings, the patient says this was not the outcome they hoped for and they no longer wish to pay your fee.
In some instances, their concerns may be easily remedied. For example, perhaps the history was not detailed as accurately as the patient felt it could have been.
But when the patient challenges your conclusions and any diagnoses made, the way forward from here can be less obvious, even for more experienced clinicians.
In the GMC’s Good Medical Practice guidance, it emphasises the importance placed on your obligations when communicating information.
The guidance states: ‘You must be honest and trustworthy, and maintain patient confidentiality in all your professional written, verbal and digital communications. (Paragraph 88).
‘You must make sure any information you communicate as a medical professional is accurate, not false or misleading.’ (Paragraph 89).
This means you must take reasonable steps to check the information is accurate, you should not deliberately leave out relevant information or minimise or trivialise risks of harm and you should not present opinion as established fact.
Therefore, while a patient may not be happy with the outcome of a consultation, you are still duty-bound to act in accordance with your obligations and to be open and honest with your conclusions.
Case study
It may be helpful to consider an example here for illustration:
Mrs A was concerned regarding their eight-year-old child and decided to approach a private consultant in child and adolescent psychiatry for a consultation to explore the child’s change in behaviour.
During the consultation, the psychiatrist spent some time exploring the child’s history and came to the diagnosis of depression and recommended that an ADHD assessment be considered.
Mrs A disagreed with the diagnosis of depression and felt the psychiatrist should have been able to diagnose attention deficit hyperactivity disorder (ADHD) during that consultation, rather than potentially have to pay a fee for a further assessment.
She also felt time was wasted discussing the patient’s history when this could have been gleaned from reading a report they had previously submitted.
As a result, Mrs A either wanted the letter rectifying, the further assessment funded by the psychiatrist or to have the fee waived for the consultation already held.
The psychiatrist, already aware of their obligations and satisfied with the letter written, declined to alter the letter or accommodate Mrs A’s other demands.
Feeling bullied
As a result, Mrs A sent several messages putting in a subject access request (SAR) and requesting the psychiatrist’s GMC number. The psychiatrist felt bullied by Mrs A and pressured into doing what she wanted.
In this scenario, when there is so much activity and pressure from Mrs A, it can feel overwhelming and difficult to navigate a way forward.
Putting the request for the psychiatrist’s GMC number and SAR aside – these would, of course, need to be considered and complied with – the crux of the matter is focusing on Mrs A’s dissatisfaction with the assessment received.
In instances such as this, while this can be daunting, it can be worthwhile to consider offering a meeting with Mrs A.
Within this meeting, the psychiatrist could explore the concerns raised by Mrs A, explain how they came to their diagnosis and recommendations, and answer any queries Mrs A may have.
Written summary
It is helpful to follow-up meetings such as this with a written summary of what was discussed, and any conclusions drawn.
This is beneficial to ensure all parties are on the same page after the meeting, but also to demonstrate an audit trail of steps taken to remedy the situation, which would reflect well on the psychiatrist if the matter escalates.
Should Mrs A be reluctant to meet, this may well not be an option.
In line with the earlier mentioned guidance from the GMC, if the clinician feels their communications meet the thresholds outlined, then they are under no obligation to alter their letter.
While the fallout from the situation with Mrs A may be unpleasant and may unfortunately result in a complaint, the focus from the clinician’s point of view would need to be on conflict resolution and reflecting on the situation to ensure they are satisfied with the standard of care provided.
Set patient’s expectations
This situation is, of course, less than ideal for the clinician involved, and for the party seeking treatment.
One way to try and mitigate the risk of such a situation, and potential escalation, is for the clinician to have a candid discussion with the patient or responsible guardian before providing care to set their expectations about the possible outcome.
The GMC’s guidance on Decision-making and Consent reflects this. It says: ‘The exchange of information between doctor and patient is central to good decision making.
‘It’s during this process that you can find out what’s important to a patient, so you can identify the information they will need to make the decision.
‘The purpose of the dialogue is:
A. To help the patient understand their role in the process and their right to choose whether or not to have treatment or care.
B. To make sure the patient has the opportunity to consider relevant information that might influence their choice between the available options.
C. To try and reach a shared understanding of the expectations and limitations of the available options.’
And paragraphs 18 and 19 of the guidance continues: ‘You must seek to explore your patient’s needs, values and priorities that influence their decision-making, their concerns and preferences about the options and their expectations about what treatment or care could achieve.
‘You should ask questions to encourage patients to express what matters to them, so you can identify what information about the options might influence their choice.’
What the patient wants
Based on this guidance, it is vital that a clinician establishes what it is that the patient is expecting from the consultation, what is important to them with regards to potential outcomes and to set their expectations as to how likely this may be.
For example, in Mrs A’s case, had the psychiatrist been aware she was seeking an ADHD diagnosis at the consultation, they could have set her expectations accordingly and explained the potential pathway from this consultation and the steps necessary to provide their child with appropriate care.
This would ideally have mitigated the risk of the subsequent behaviour from Mrs A and enabled a more positive and productive working relationship.
The psychiatrist may also wish to ensure they documented any conversation where expectations are set so there is a clear audit trail if any issues arise later.
Private practitioners can contact their medical defence organisation for medico-legal advice and support with handling a situation like the one described above.
If any assistance be needed on the financial aspect of a situation like this, then clinicians may wish to contact an organisation they belong to, such as the BMA, who may be able to assist.
Fin Wright (right) is a case manager at Medical Protection
