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Dealing with a patient who shops around

Case

history

'I don't normally see you doctor, but my daughter recommended you because you'll be the most up to date.' You see Mrs Jones has already consulted three partners about her abdominal pain; one has referred her for investigations that have been negative.

Dr Melanie Wynne-Jones discusses.

How can we resist flattery?

Doctors still get more compliments than complaints; most of us enjoy feeling we have made a difference, and feeling appreciated is important for our morale, so save thank-you letters and positive feedback in your appraisal portfolio1.

However, a few patients try to manipulate their doctors so be wary if a compliment (or gift) seems excessive or undeserved.

Beware, too, of phrases such as 'you're the only one who listens', 'no one understands my problems like you do' or 'you're so thorough, I expect you'll probably refer me to hospital'.

Does continuity of care really matter?

Continuity of care is a cornerstone of traditional British general practice and consistently scores highly in patient surveys, although fewer patients see their registered GP exclusively these days.

Continuity has both clinical and resource implications and affects satisfaction levels on both sides. A GP who knows the patient may be more trusted by the patient, or use his/her existing knowledge of the patient, their beliefs, their family and their general situation, to:

 · Formulate more relevant/ complete diagnoses and options ­ for example both GP and patient may feel confident in attributing new symptoms to stress because of their past shared experience.

 · Successfully negotiate appropriate and acceptable management plans, including referral/non-referral, prescription/non-prescription, doing nothing.

 · Use the drug 'the doctor' to help the patient2.

 · Avoid unnecessary, expensive or invasive investigations.

However, continuity has its own risks, including the GP making assumptions (thus avoiding certain areas or not probing deeply enough), cosiness which can lead to collusion, and tunnel vision (the patient may wrongly assume the GP knows all the facts, and should not have to identify a GP's omission or educational need).

Why do patients shop around?

Patients may consult more than one doctor about a problem because:

 · Their usual GP is unavailable ­ the problem is urgent, or the GP is part-time or on holiday.

 · Practice organisation discourages continuity ­ this is more likely with advanced access, especially if the doctor providing telephone/ emergency consultations changes each day.

 · They genuinely want a second opinion (this is a strength of group practice).

 · They don't like or trust the first doctor (for whatever reason).

 · They don't like the first answer or treatment (particularly if they have unaddressed ideas, concerns or expectations) or have been denied something (such as a referral or treatment).

 · They are playing some sort of game involving relationships, work or financial gain that requires a GP's participation.

 · They are trying to play one health professional off against another (medication is often involved); it is important not be drawn into this.

What does the new contract (GMS2) say about shopping around?

Patients can already seek medical advice elsewhere; A&E and out-of-hours providers have always been available and do at least tend to provide the GP with information.

NHS Direct and walk-in centres, for example at airports and stations, tend not to inform the practice and many GPs are worried that GMS2, which allows a range of providers into the arena, will destroy continuity of care forever.

Under GMS2, patients will be registered with the practice rather than an individual GP; this in itself is not necessarily a problem, and works in most group and PMS practices.

But PCTs will be allowed to commission out-of-hours and additional/enhanced services from other providers, including non-NHS organisations, even if the practice believes it could offer such a service. Patients may even be able to register with two GPs ­ one where they live and one near work; the roles of pharmacists and nurses are also to be extended.

The potential for duplication of effort and resources, prescribing errors and other risks are obvious, but we are promised that patient choice and nationally accessible electronic health records ­ due by 2010! ­ will overcome this.4

How should you deal with Mrs Jones?

It may be time-consuming but taking a full history of what has happened prior to her consulting you should avoid pitfalls and save time in the long-term. How she describes her encounter with each of the previous doctors, what they did (cross-referenced with the doctors' notes), how she felt about it, and the outcome will help you to decide what to do next.

Keep an open mind and don't comment until you have all the facts. Take care not to step on your colleagues' professional toes or openly criticise them (although they may be delighted to hand her care over to you).

Tell her if you need time to consider her case, or discuss her with your trainer, a partner or a consultant, before proceeding. This may confirm that everything possible/desirable has been done or suggest a way forward.

It's often said that the last doctor to see the patient makes the diagnosis. If she and you are lucky you will identify the correct course of action, and even possibly cure Mrs Jones, thus justifying her faith in you.

However, patients whose shopping around causes major problems ­ for example, frequent requests for benzodiazepines ­ should be encouraged to stick with one doctor; how strongly this is enforced will depend on the particular circumstances.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

 · Patients who shop around may do so for convenience or for a reason

 · Enjoy appreciation for a job well done ­ be wary of gratuitous compliments

 · Continuity

of care is usually desirable but can have drawbacks

 · The new GP GMS 2 contract will change the GP's central role in the provision of care

References

1 GP Appraisal Material for Form 3 section 3. Relationship with Patients

2 M Balint. The Doctor, His patient and The Illness, 1957.

Republished 2000. ISBN: 0443064601. Churchill Livingstone

3 BMA www.bma.org.uk/ap.nsf/Content/gpcwebupdate1912

4 Government strategy paper 'Building on the Best; Choice, Responsiveness and Equity in the NHS' , December 9, 2003; draws out and develops the main themes that emerged from the "Choice, Responsiveness and Equity" consultation. www.doh.gov.uk/choiceconsultation/index.htm

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