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Hard to keep 'mum' about GP treating a relative

3 GPs discuss a problem

3 GPs discuss a problem

Case history
After university you returned to work as a GP in your home town. Your parents are still registered with the family practice, although your family GP has been replaced by a contemporary whom you like. You see him at clinical meetings and some social events, but are careful not to discuss your parents' health.

Your mother is now well into her 80s and has become increasingly breathless; she is overweight, hypertensive and suffers from insomnia. She always tells you about her various symptoms, but you encourage her to consult her own GP, because you find it hard to be objective, and because you consider it unwise to treat your own relatives.

However you are becoming increasingly concerned her GP doesn't seem to be arranging the investigations you would consider necessary, and find some of her medication puzzling to say the least. According to your mother, he is very reassuring and always tells her not to worry.

1. View from Dr Declan Fox

'My son does not trust my doctor....' On the face of it, a disturbing story with the potential for trouble. I can't just call up her GP and ask what's happening; apart from confidentiality, the GP may feel threatened and react badly.

Mother might not have very much wrong with her at all, other than being old, inactive and de-conditioned. Or she may not be telling her GP enough of her symptoms to enable him to make a diagnosis. Or she might not be telling me what her GP said because she misunderstands or does not want to hear it. Perhaps she has rejected his advice in the past and he has decided against forcing the issue, preferring to maintain their relationship so he can help if there is a crisis. She may have had tests I am unaware of because she has not told me, has forgotten or does not want to talk about them. She may have refused other medication or may have it stashed away at home.

I have not taken a full history from her and I have not examined her. Therefore I have not put myself in a position to make a diagnosis. Therefore I really cannot make much of a judgement about her GP's management of her. All I am sure of is here is what I observe; that she seems to be deteriorating.

Discussion with my medical defence body and with a local senior GP (a LMC member would be good) would be wise before doing anything.

The most important immediate question is: does the GP's management seem dangerous? If so, I have to do something about that but I shall certainly take advice first.

My medical defence advisers will probably say I should ask my mother for permission to discuss her case with the GP and then go do it. Chances are I will find there are all sorts of things going on that I don't know about. I just might find gross incompetence though that seems unlikely. If I do then I shall have to convince my mother to go elsewhere as well as ensuring that the right things get done to help this doctor and protect his patients.

Declan Fox is a GP in Newtownstewart, Co Tyrone

2. View from Dr Zoe Rogers

We all know it is difficult to be the doctor to another GP and their family. Confidentiality will prevent the GP talking directly to me about my mother's health. Something may be going on that my mother does not want me to know. It would be best for me to talk to my mother and express concern that what she is telling me does not seem to make sense. I would ask to accompany her to her next appointment to understand why her GP is treating her in this way. This would be far preferable to my mother going back to him on her own and telling him I am not happy with her treatment.

If she does not want me to attend I will have to respect her decision. If I think there is information she has not told her GP, then I could drop him a note expressing my concerns but explaining that my mother does not want me involved. I would be reluctant to do this as I know from the other side how difficult it is to respond to this kind of information.

If my mother agrees, hopefully I will then understand what is going on, and be happy with her investigation and treatment. It would be nice if we could have more than 10 minutes for this and I would try to organise this with the practice receptionists. If my mother and/or I are unhappy after this consultation, we could consider seeing another partner or moving her to another practice, but I would not treat her as one of my patients.

It is a challenge as a doctor to balance the need to look after your family and not be left feeling 'if only I had done more' with the need to give the medical staff involved the freedom to get on and do their job. It is never a good idea to treat your family as patients except in an absolute emergency.

Dr Zoë Rogers is a Part-Time GP Principal in Aylesbury

3. View from Dr Alex Willams

This has the potential to become quite a difficult and at best embarrassing situation. Uppermost is that the patient (my mother) is happy with the treatment she is receiving, so my own concerns are more about clinical competence and appropriate decision making. It may be useful to attend a consultation (if this is acceptable to my mother and her doctor) and try and some understand for the therapeutic and clinical processes. It may allow the opportunity to make some decisions on direct observation rather than perception and hearsay. It may be that my concerns are unfounded and that my colleague's performance is unblemished, however if all is not what it seems then further action may be necessary.

First, I would gather the opinion of fellow professional colleagues, especially his partners and attached professional staff, if appropriate. Have others any concerns, if so has any action been taken? It may be prudent to make enquiries with the LMC, the clinical governance lead for the PCT and consider further actions including sharing me concerns with the GMC. We are obliged to share concerns and take appropriate actions if we have any issues about our colleagues, it is no longer acceptable to turn a blind eye or leave this to others. The outcome may be in the hands of others and the safety of the patients must be uppermost.

I need to allow my parents own professional advisers to decide about their clinical care. I do not want to start a witch-hunt if this is not appropriate, and jeopardise the reputation and career of a colleague, however 'do no harm' is ringing in my ears and god forbid this is another Shipman or some equally perverted mind at work, that I would never be able to forgive myself, if it was discovered they that hurt or harmed my kith and kin or others.

Dr Alex Williams is a GP trainer in Exeter

Learning checklist

Being involved in relatives' care

Good Medical Practice (2006) General Medical Council (parageaph 5) says:' Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship. This usually means not registering them where you work; if this is unavoidable (for example in rural areas), ask a colleague to care for them.

It's difficult to care safely for relatives because:

• They may withold information because they wish it to remain private or think you know already; you may find it difficult to ask them potentially sensitive questions

• You are unlikely to hold their medical records, and their doctors may not divulge information.

• It's hard to be objective about symptoms/investigations/diagnosis/management because of relationship dynamics, your personal fears or transmitted anxiety. You could either over-/under- do it.

• You may be pounced on for advice in inappropriate situations – for example family social occasions

• You may feel embarrassed to admit (or not recognise) your lack of knowledge or expertise

• Relatives may not comply with your advice

Dealing with patients' medical relatives

Paragraph 29 of GMP says: 'You must be considerate to relatives, carers, partners and others close to the patient, and be sensitive and responsive in providing information and support, including after a patient has died. In doing this you must follow the guidance in the document Confidentiality: Protecting and providing information.'

• If the patient has capacity you must obtain informed consent to divulge information to any relatives, including medical ones.

• The Mental Capacity Act 2005 defines how doctors should behave when a patient does not have capacity

• Doctors' families are not immune to dysfunctional relationships

• Discussions with medical relatives are usually conducted in medical-ese and may inadvertently disempower the patient

• The patient, not the medical relative, must make the decisions

• Treat medical relatives with the same care and compassion as you would any other relative, for example when breaking bad news.

Concern over another GP's standard of care

Damned if you do, and damned if you don't! GMP paragraph 43 says 'You must protect patients from risk of harm posed by another colleague's conduct, performance or health. The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary.' And paragraphs 46-47 say 'You must treat your colleagues fairly and with respect………You must not make malicious and unfounded criticisms of colleagues.' If you have serious concerns about another doctor's performance, consider speaking in confidence to:

• The doctor concerned

• A partner in your practice

• Your defence society

• The Local Medical Committee (non-statutory responsibilities include sick doctors and clinical governance

• A solicitor

This learning checklist was compiled Dr Richard Stokell, a GP trainer in Birkenhead

Dr Declan Fox Dr Declan Fox

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