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Gold, incentives and meh

How GPs can get round problems of patient notes for insurance firms

Three GPs share their approach to a practice dilemma

Patient demands that you reduce his weight

Case history

After a tirade against the NHS, a US-born UK national mentions he would like to try an obesity treatment.

He lists a number of treatments that have failed to give long-term improvements to his BMI of 37 during previous attempts to diet, although he says short-term weight reduction was sometimes achieved. He says he has no intention of cutting out cheese or taking up exercise.

He is keen to treat all aspects of his health with tablets and knows that sibutramine will not interact with his statin or diabetic and antihypertensive medication. How do you proceed?

Dr Rachel Pryke

'Get used to it, this is set to become commonplace'

I may as well get used to this scenario as it is likely to become commonplace as the medicalisation of obesity takes hold. We do not yet have an in-house obesity clinic, which would probably address this scenario more effectively, but we are in the early stages of planning this.

First, I would look for the minimum commitment by asking him to attend for a specific appointment to go through the pros and cons, measure BMI and plan realistic goals. He would be informed that attendance for regular weighing was part of the deal.

At this appointment, I would explore his aims and explain that the maximum sustainable weight reduction is likely to be only 10 per cent of body weight, leaving him still in the obese range. Only if this were maintained would I suggest further weight loss.

I would note on the computer what BMI aims we were looking for, plus the timescale,

in case he saw a different partner for


I would mentally file him in the 'fail' pile in view of his frank refusal to increase exercise, while still doing my best to encourage him to fit in practical ways to get fitter, such as parking further from work and using stairs.

His chances of long-term weight reduction remain inversely related to his BMI and so I would cynically look for early reasons to stop the sibutramine in order to protect our drugs budget. I would equally cynically make sure all his QOF point boxes were ticked too.

Rachel Pryke is a part-time principal in Redditch, Worcestershire

Dr Iain Mclean

'Implications of failure to lose weight should give him food for thought'

With the risk factors described in this scenario, this curious man is likely to become an invalid with high demands on both the NHS and social services. A careful preparation of the rules of engagement should prove helpful in the future.

The sub-text to this consultation is 'I've come for Reductil and won't accept any reservations you may come up with'. He may or may not be thinking that he will prove this treatment a failure too.

You have three options ­ refuse treatment, prescribe, or refer.

A blank refusal to treat unless your patient 'engages constructively' is justifiable and within the spirit of NICE guidelines. These say that prescription should be limited to those exercising and making behaviour modifications. Ask for evidence of weight loss, dieting or exercise.

This is likely to end the consultation, and your man is likely to change doctors and register a complaint. But at least the problems will have been handed on. Compliance with the request is justifiable if interpreting guidelines and prescribing data literally if not in spirit.

There are safeguards that must be taken and recorded in the notes. The side-effects, safety and efficiency of this agent should be explained and a description of its pharmacological group useful. Jot down the programme of pulse and pressure monitoring and explain that failed or late attendance, sight, hepatic or renal changes will result in immediate treatment withdrawal.

Failure to lose weight will have the same implication. With luck this will give your patient food for thought and if he proceeds it will be with a clear understanding of the treatment and a wish to prove that he can reduce his risk factors.

Referral is the third option and this may be appropriate. There is likely to be dietitian advice in the past and further contact will only be frustrating, wasting everyone's time and effort. If you have access to an obesity unit with surgical tratment options, asking if he is really serious about weight loss and would he go to a tertiary centre might be interesting.

Iain Mclean is a GP in Wigtownshire, Scotland

Dr Rodger Charlton

'It is reasonable to expect him to meet you halfway'

This patient sounds like an angry patient. However, his views on the NHS should not influence one's clinical management. He has both diabetes and hypertension which will be exacerbated by his obesity.

It is important therefore to support him in his quest to lose weight and steer him in a direction likely to be successful in achieving a healthier BMI. Weight loss should pay dividends in improved control of both his diabetes and BP.

As a GP trainer I put a lot of emphasis on registrars finding out the ideas, concerns and expectations of patients and this case is no exception. Is his anger really a defence against low self-esteem and against an expectation that you will pass judgment on his lifestyle and eating habits?

He has made it clear what his concerns are regarding medications other than sibutramine and their possible interactions with his other medication.

His expectation is to receive sibutramine and he has own ideas regarding the place of diet and exercise in managing his obesity and that he would prefer to treat it with tablets.

It is an easy trap to fall into to take umbrage at his ideas and his derogatory views on the NHS and so make the consultation doctor-centred. However, this is likely to achieve little and one needs to guard against this and be patient-centred. So, yes, you should consider taking up his suggestion of prescribing sibutramine (assuming his BP is under satisfactory control) but it is reasonable to expect him to meet you halfway.

Rodger Charlton is a GP in Solihull and director of undergraduate GP medical education at Warwick Medical School

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