Did senior partner blunder in anger over home visit?
Nora is 83 and quite active and independent despite troublesome osteoarthritis, angina and atrial fibrillation for which she takes warfarin. She attends several times a year for a routine check-up and to discuss her various aches and pains. Today she is complaining of severe limb girdle pain and stiffness associated with headache. She tells you she suddenly lost the vision in her right eye two weeks ago.
On reviewing her notes you see her last consultation, four weeks ago, was a house call. Your senior partner visited, wrote 'Headache, myalgia, lassitude ?PMR, to attend surgery for ESR, no medical justification for visit request', and prescribed
Dr Sohail Butt
A critical event involving care from the senior partner could be very difficult for the practice to deal with.
My initial concern would be to give the best possible medical care to Nora and try to protect her remaining vision and help restore her mobility. Physical examination may offer further diagnostic clues to the cause of her symptoms such as tender temporal arteries, muscular tenderness and restricted movement of the limb girdle.
If the history and examination are suggestive of PMR and temporal arteritis I would give her 60mg of prednisolone immediately with PPI cover, and refer her to the on-call medical team for confirmation of diagnosis and follow-up care.
I would ask Nora to telephone me as soon as she is discharged so I can review her. Offering good medical care and demonstrating concern at this stage may reduce the likelihood of complaint or litigation in the future.
I would see the senior partner alone after surgery and let him know what has occurred.
This may allow him to review the medical notes and seek advice if he has any medicolegal concerns. The senior partner may fill in one of our significant event forms if he feels this is appropriate, as there may be useful learning points for the practice. This would then be discussed at our next practice clinical audit meeting.
This would allow us to review our policy on home visit requests, blood-taking arrangements and follow-up procedures.
With the benefit of hindsight it would appear the consultation and the subsequent medical record entry may cause the senior partner difficulties in the event of complaint or litigation.
Through discussion we may identify useful strategies for dealing with this difficult situation and recording consultations, which may improve patient care in the future.
Dr Edward Farnan
This, as my trainer would have said, is a problem. In fact there are several.
The first is Nora, who almost certainly has giant cell arteritis. She needs to be started on high-dose steroids now. She takes multiple medications, including warfarin, for her other significant illnesses. Given the quantities of steroids necessary, at least initially, side-effects and interactions are likely.
Having already lost sight in one eye, possibly permanently, the other is at risk. I would want to speak to my local ophthalmologist today to agree a management plan until Nora can be urgently assessed. I would also want to speak to Nora. She has remained independent and active until now.
Going blind in one eye at her age is a major impairment and will significantly impact on her ability to function. At the very least she is going to need a lot of support from family, friends and the primary care team to adapt. Close follow-up by all concerned would be required.
I would then address the two problems arising from the initial consultation. First, what happened to the ESR? It seems likely Nora did not attend as requested, or if she did, a probably abnormal ESR was not appropriately dealt with. Either way, we have a practice system failure, which would need to be rectified to prevent further problems.
Finally, there is the problem of the original note. My senior partner was clearly unhappy at having to make what he felt was an unnecessary visit. But the clinical notes are not the best place to vent these feelings.
Furthermore, if he made Nora aware of his displeasure, overtly or otherwise, she may have been put off attending for the ESR, or worse, contacting us when the situation deteriorated.
A quiet word, including a hint to run things by his defence organisation, might do no harm.
Dr Clare Wilkie
This situation is full of risk for both patient and doctor.
I need to start Nora on oral steroids straightaway. I would take bloods: for ESR of course, but also for thyroid function, calcium and phosphate, FBC and glucose to support or exclude differential diagnoses.
Nora needs early referral with a view to artery biopsy but clearly steroid treatment cannot wait on this. Psychiatric referral may also be appropriate, depending on my assessment of Nora's mental state.
I think my senior partner is also at a different kind of risk. His actions of a month ago would almost certainly be counted indefensible though he considered the possibility of PMR he did not arrange investigations within a reasonable time, did not institute essential treatment and spiced up his note with a comment about the appropriateness of the visit request that was both irritable and unjustifiable in the case of a frail 83-year-old.
A lawyer would probably attribute Nora's loss of vision directly to my partner's failure to act. It will be a delicate task to raise this with my partner and find out why he acted as he did, both for the sake of practice patients and the doctor himself. Was he overwhelmed with fatigue or burn-out? Does he simply not know enough about arteritic diseases in elderly people does he need to put them in to his PDP for the year? I will need to be both diplomatic and supportive.
Should I even hint to Nora that my partner's actions were questionable? Principles of complete honesty and transparency would suggest I should, but in the interests of a continuing working relationship with my partner and a continuing therapeutic relationship between Nora and the practice, it would be better to leave the explaining and ideally apologies to my partner.