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Costing out heart failure test

Three GPs share their approach to a practice problem

Case history

Mrs Byrne was diagnosed with chronic fatigue syndrome following a viral infection last year. She seems to be bearing it bravely and says she 'hopes to get back to work one day doctor'.

As part of her investigation, you found her thyroid function was within normal limits. But the local ME group leader has told her the test is unreliable in people with chronic fatigue syndrome and she should ask you to prescribe thyroxine. You are reluctant to do so.

The next day a complaint arrives in which she accuses you of being unsympathetic and out of date and threatens to go to the press.

Dr Nigel Hunt

'I wouldn't give levothyroxine to someone with ME/CFS with normal thyroid results'

At times like this you ruminate and reflect on why things went wrong. Were there failings in the way I handled the consultation? Did I rush and not fully explore her problems? Was I aware of all the facts?

Undisputedly there was a mismatch in her expectations and what I felt I could safely agree to at the time. If I had been unsure of my facts then the best approach would have been to be honest and say 'I don't know' followed by 'I'll research it further and get back to you'. Perhaps I missed an opportunity to ask what other support she might need.

Where should I search for the evidence? While I have had little experience of using the internet during consultations (there just isn't time), away from the consultation, typing a short phase into a search engine quickly identifies useful avenues for further research on this subject. The national ME/CFS charities also have helpdesks and access to professional advice.

As it is, this is red flag territory and I would not give levothyroxine to someone with ME/CFS with normal thyroid results.

The bottom line is that if there is any doubt about Mrs Byrne's thyroid function then it would be appropriate to refer her to the local endocrinologist. This may be necessary in any case to defuse the situation.

Nigel Hunt has been a GP for 18 years – he practises in Chelmsford, Essex, and was a member of the Chief Medical Officer's working group on CFS

Dr Claire Pedder

'Her threat to go to the press doesn't cause me much consternation – there's no shock-horror'

I would feel disappointed and aggrieved that Mrs Byrne has responded to our last conversation in this manner. I'd want to vent my irritation in a safe place before working out my response (the cat had better hide again!).

Does she have any justification for her complaint? Was I abrupt and unsympathetic at our last meeting, or did she feel I wasn't taking her problems seriously? In my experience, patients don't usually complain when they think the doctor has been understanding and thorough, although there are always those delighted to prove the exception.

I would respond to her complaint in writing, being careful not to lay any specific blame on my doorstep, but expressing sympathy for her situation. I would explain more fully my concerns about prescribing thyroxine and describe some of the potential problems of iatrogenic hyperthyroidism.

But I am not an expert on managing people with chronic fatigue syndrome (is anyone?!) and would express my willingness to carry out an internet search to update my knowledge. Advice from a local specialist would be helpful too.

Her threat to go to the press doesn't cause me much consternation. In the absence of a sexual scandal or dramatic life-threatening infection, the story lacks the shock-horror factor needed to sell newspapers. And anyway, when do I get the time to read one?

Claire Pedder finished the VTS in 1996 – she is now a GP principal and trainer in Edinburgh

Dr Rodger Charlton

'I would suggest Mrs Byrne brings the ME group leader to a subsequent consultation'

My first reaction is that my communication with Mrs Byrne couldn't have been adequate and I should offer to see her to discuss the issue again. The medical defence organisations tell us the most frequent cause of complaints relate to poor communication, and this is no exception.

Mrs Byrne is obviously angry. Indeed she is angry with me for not giving her what she believes she needs, and perhaps she is also angry with herself because she is ill and feels unwell. We often stress to our GP registrars that it's important to seek and address the patient's ideas, concerns and expectations; this consultation has ended in a complaint because I have failed to do this.

I would be keen to discuss this matter with my partners to find out how they might manage this problem while adhering to our complaints procedure. I'd also want to find out whether I am sufficiently up to date on ME and the possible use of thyroxine. I would also do an internet search for the latest thinking in this area.

Ideally, if I had enough time on my hands I would suggest Mrs Byrne brings the ME group leader with her to the consultation. Failing that, she could bring her husband or a friend who can listen to my explanation and help recall this information when she has left the surgery.

Assuming Mrs Byrne is willing to come I need to be sure I have set aside adequate time to listen to her point of view.

Rodger Charlton is a GP principal in Hampton-in-Arden, Solihull, West Midlands, and has been a GP since 1987

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