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GPs' views: Last gasp

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

John Smith is 21 and has severe and unpredictable asthma. He regularly turns up asking for an immediate prescription for his bronchodilator; in return he agrees to make an asthma clinic appointment, which he cancels or misses. He claims he does not use his long-acting bronchodilator or steroid inhaler because he cannot afford the scripts, and anyway he's 'fine'.

Every few months he presents with acute bronchospasm requiring nebulisation and steroids, and occasionally admission. Attempts to reason with him and even warnings about the risk of death have failed. You can't remove him because there is no other local practice. Today your surgery is overbooked; John is at reception yet again asking for an immediate prescription for his bronchodilator.

Dr Alex Williams

'He perceives parental overtones in requests to see the nurse, and reverts to childlike rebellion'

This is a situation I have encountered with some patients with asthma and relates to their perception and understanding of their asthma. The first responsibility is to the patient and so I would ask the practice nurse to assess him with a peak flow and some simple observations. If these showed a low peak flow, given his history it would be necessary to nebulise and consider a course of oral steroids.

Non-response to the nebuliser would dictate further hospital assessment and probable admission. If he just had a mild attack then a prescription for his short-acting bronchodilators could be issued. Although the timing could not be more awkward I need to engage him in a dialogue. I would want to try and explain the illness to him in terms he can understand. I have a pictorial representation of a cross section through an airway showing how it becomes progressively narrowed as the disease progresses and is not treated adequately.

The bronchodilators become less and less effective. He will need to understand that preventive inhalers do not work straight away and may take several weeks to have an impact and will need to be taken at an effective dose. Ultimately he is an adult and needs to take responsibility for his own illness, however his non-response could be viewed as a crossed transaction if we were looking at the consultation in behavioural terms. Over the years I have found it very helpful to explore interactions that do appear dysfunctional.

He may perceive 'parental overtones' in the requests to book in with the asthma nurse, or take the preventers and consequently reverts to a child-like state of non-compliance. It is necessary to switch the transaction to adult to adult. I would encourage him to come and see me at the end of a surgery where I might have more time to deal with this. I would hope to reinforce the messages and try and make him feel responsible for his own health as well. If we could get him on side he might consider using a peak flow meter and running a self-management plan for his own deteriorations in future.

Dr Trevor Rees

'Is he ill or is he just trying to bypass the usual repeat prescription system?'

At 21, John is old enough to understand that however much he tries to think he is fine, he isn't. He has a potentially life-threatening chronic illness, and he has to understand that his current attitude towards his asthma is dangerous. Despite the fact that I'm under pressure in my surgery, it's time for me to take the chance for a face-to-face consultation as I know from previous experience that any promises John makes to come to the asthma clinic are empty ones.

As soon as I finish my current consultation, I'd call John down to my room. I'd assess the validity of his current request for an immediate prescription. Is he ill, or is it just a matter of convenience based on his previous success at procuring his medication by by-passing the usual repeat prescription system?

Once again, I'd reiterate the seriousness of his asthma, and the fact that inadequate management not only might lead to premature death, but almost certainly will lead to more severe symptoms later in life. All this would be carried out in a calm and non-judgmental atmosphere, so hopefully John might be convinced.

Finally, I'd tackle his non-compliance by finding out why he can't afford prescriptions. He might be entitled to financial help and I'd point him in the direction of the Citizen's Advice Bureau if appropriate for help in any claim he might have. If he has to pay for his medication, then combining his long-acting bronchodilator and steroid into a single device would save prescription charges and aid compliance.

Putting more than one inhaler at a time on the prescription would also help. He might also save money by having a pre-payment certificate.

Dr Zoe Rogers

'We cannot force competent adults to conform to our wishes'

It is the unpredictability of general practice that makes it interesting and also stressful and frustrating at times. We cannot force competent adults to conform to our wishes. All we can do is present information in a way that they can understand and hope that they will use it to make sensible decisions. Despite the fact that I am in the middle of surgery I would try to find the time and energy to overcome my frustration and see him while he is here. Making an appointment for him to come back seems unlikely to be successful.

I wonder whether Mr Smith is either immature or in denial about his asthma. In either case it is important that I have kept good notes of my advice to him to protect me from any future criticism about his management. Perhaps he has difficulty attending surgery appointments because of his job or a chaotic lifestyle. Even if this is the case his repeated failure to attend appointments needs to be addressed.

I find it hard to believe that the cost of prescriptions is really the issue, after all presumably he is managing to find the money for his emergency steroids and his ventolin inhaler. If money really is an issue, then an inhaler combining steroid and a long-acting bronchodilator would save him some money, or perhaps a three or six-month prepayment of prescriptions might help. If he is a smoker he needs to give up smoking and be offered the appropriate help.

Asthma monitoring does not require a doctor; indeed he may respond better to being monitored by a practice nurse. I would try hard to convince him that it is worth his while to both take his regular medication and also come back for follow up. It would be worth looking at the protocol reception has for dealing with requests for emergency prescriptions. The way these are handled can either add stress or protect a doctor from it.

Although it is important that doctors are not interupted for every prescription request a patient who needs to be seen must not be turned away. Lastly, I will need to let out a large sigh after he has left as I am sure he will be back again with a very similar request.

What does this incident teach us?

Learning checklist

  • Managing the difficult patient - Not all patients are easy to manage, so don't think it is your fault.
  • Patients with difficult problems take time, so be calm and solve the problem in the best way you can for the patient.
  • Try to see the problem from the patient's point of view
  • Make good, contemporaneous records of every interaction with such a patient.
  • Avoid consultations in public places like the reception area.
  • Always be prepared for unexpected violence, both physical and verbal.
  • Try to have the same doctor involved most of the time, if practical.
  • Removal is a last resort. Follow guidelines1.
  • Failure to comply with treatment is not a reason for removal.
  • Repeat prescriptions
  • No system is perfect.
  • Be prepared to bend house rules.
  • Make sure a patient understands the system. If not, explain it to them, even if you have done it before. But not all patients can cope with a repeat script system. If they can't, see them regularly.
  • IIf patients cannot afford regular repeats, consider alternatives including prescribing more or privately.
  • Make sure receptionists know what to do with an acute script request.
  • When analysing an event like this, involve the reception staff.Improving self-management
  • Ask why patients are not coping.- Involve colleagues in both primary and secondary care.
  • Consider psychosocial issues.
  • Discuss with the patient's permission the situation with family or friends. A useful insight may be gained.
  • If you are not winning, try to make as much impact as possible. Don't give up.

Dr Harry Brown is a GP in Leeds and a trainer

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