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A new patient latches on to you and sees you every week with trivial problems, some with psychological overlay.

Over a period of time this patient has suffered from many symptoms and has had countless investigations but no serious pathology has ever been uncovered.

The patient is of the opposite sex, good looking and always comes at the end of the surgery.

The patient takes 20-30 minutes of your time, invariably overstaying their welcome, and in due course starts to make suggestive comments to you.

These appear to be banter rather than anything else but are becoming more frequent.

The patient's medical problems remain virtually non-existent. How would you handle the situation?

This could develop into a real problem. As GPs we are all taught to develop a good rapport with our patients, be empathic listeners and generally come across as 'nice guys'. It can be very easy for some patients to misinterpret these friendly overtures.

Initially I would discuss this patient with my other partners. I would tell them he is making me feel uncomfortable. He may be working his way around the partners and one of my colleagues may have experienced a similar problem in the past.

I would try to explain to the patient that these suggestive comments are inappropriate. I would aim to appeal to his good sense and explain that his behaviour is interfering with my job as his doctor.

This may be enough to solve the problem and he may leave, hugely embarrassed, never to darken my door again. Alternatively, my comments could be ignored and I may have to ask our practice manager to write explaining that his behaviour is unacceptable.

In this letter we could suggest that we may have to remove him from the list. In the meantime I could request, via a message on our computer front screen, that he sees other doctors in future.

It is possible that such a patient could become litigious and I would be extremely careful to make good notes. I would also request a chaperone for any intimate examinations and take advice from my defence body.

But with luck the situation will not deteriorate and can be settled in an amicable way.

This situation could become a serious complaint and will have to be handled with tact and sensitivity. The patient appears to have a track record of non-organic illness and would raise the possibility of Munchausen's syndrome. Clearly there may be a psychological component to her symptoms and presentation. She may have developed an abnormal belief or even an obsession.

First, I would talk to my partners and practice manager to get some ideas on how to manage the situation. It might be prudent to discuss it with my defence body and my wife in case any rumour or innuendo were to arrive home. I might discuss it with a practitioner group and it would provide fertile discussion at a Balint group.

I would arrange an appointment with the patient and ask the practice manager or another partner to attend to corroborate what was said. A contemporaneous record should appear in the patient's notes. Without being too censorious I would list the concerns that I had with her behaviour and the possibility of these being misinterpreted by others.

Clearly I would seek her response and try to listen in a caring and empathetic way. I would suggest various options for ongoing care and these would be: all future appointments to take place with a chaperone; she should register with another partner and or practice; she should accept a referral to a psychologist or psychiatrist.

The meeting could deteriorate into acrimony and she could storm out in a huff. Or there might be floods of tears. Whatever, we have to stand firm as a practice. These are litigious times and one can't be too careful.

I have not been alert to the warning signs (countless investigations, non-existent medical problems)! I would speak to my colleagues about my concerns and ask myself if the relationship with the patient could continue to be therapeutic.

The patient is adept at using strategies that prolong the consultation. I would have to be equally adept at curtailing these. I would not be rude, but some patients do need direction in terminating a consultation.

In this scenario, the patient is making suggestive comments. My response might have been misconstrued as encouragement. I would gently but firmly say that his suggestive remarks are unacceptable and that I am uncomfortable with them. I would have to prepare myself for a backlash as he might see this as personal rejection. If possible, I would tell the receptionists not to give him an appointment at the end of surgery.

I would try to direct the patient's energy in other avenues ­ suggest he sees a counsellor. I would be upbeat in reiterating that there is no serious pathology and would discourage the weekly appointments. I might have to compromise in order to contain the problem by suggesting review, although at less frequent intervals, otherwise he will

only transfer his problems to other GPs.

If I had to examine him I would make sure a chaperone was present. If I found a therapeutic relationship was irretrievable I would have to avoid future appointments, but this might be very hard, especially if he has not ostensibly caused any offence.

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