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At the heart of general practice since 1960

I didn't know you were a GP

Three GPs discuss a tricky problem

Case history

You practise under your maiden name. Sharon Jones has not seen you before though you know her vaguely from the school gate. You have spoken to her husband as he is a school governor.

Mrs Jones walks in looking distressed and wearing dark glasses. She whips them off to reveal a black eye. With a look of sudden horrified realisation she exclaims: 'Oh my God, I didn't know you were a doctor.' Her notes make a vague reference to 'stress and marital difficulties'.

Dr Lorna Gold

'A patient who begins with a lie does not rate me highly'

This consultation is off to a bad start. Any patient who begins by expecting me to believe a lie that a child could see through does not rate my intelligence as highly as I do. Of course Mrs Jones knows that I am a doctor.

The school gate grapevine will have made sure of that. Furthermore, she is well aware it is me she will be seeing today.

Experience has tempered my intellectual vanity, but I will take some satisfaction from being able to combine duty with calling her bluff. I will offer her the opportunity to see one of my partners instead. We work flexibly; this would not be a problem. I shall enjoy watching her come up with an excuse for declining.

Once that is out of my system, I can settle down to approaching the rest of the consultation as an empathic and objective GP.

Mrs Jones has deliberately chosen to consult me, despite the embarrassment of knowing me slightly socially. She clearly thinks I can be trusted.

If she finds it difficult to begin, I will show her what my partner has written in her notes, and ask whether the black eye is

related to her marital difficulties.

If her husband was not the perpetrator, she may be

offended, but I am sure she will understand I had to ask about the possibility.

If he was, I shall pass the tissues and prepare for a long, mentally draining consultation which,

unless there are child protection issues that demand immediate action, will probably be the first of several consultations in which

Mrs Jones will use me as a sounding-board while she makes some difficult and life-changing decisions.

Dr Alison Best

'If you practise where you live, boundaries are paramount'

Living in the practice area, with children attending local schools, will mean acquaintances and friends of friends are encountered in the consulting room fairly frequently. Boundaries are paramount.

GPs who live in their practice area must develop strategies to establish good boundaries between personal and professional contact with individuals. Many female GPs choose to practise under their maiden name, but perhaps this can be confusing for patients.

Mrs Jones is only a vague acquaintance, not a close friend. I would be calm and friendly and invite her to sit down. In a sensitive way, I would try to establish whether she was happy to continue the consultation with me, or whether she would prefer to see one of my colleagues. I would assure her of confidentiality, whoever she decided to see.

If our consultation continued, I would be guided by her as to how much she wished to disclose about her stress and marital difficulties ­ my usual approach anyway.

I would obviously need to examine her black eye and to establish whether she had any other injuries. Despite the allusion to 'marital difficulties' in her notes, it is important not to jump to conclusions. But if she were to disclose domestic violence, then it would be important to make sure she was safe to return home and crucial to confirm the children's safety.

If there were no immediate safety issues, I would encourage her to arrange follow-up with either myself or a colleague, since she is obviously stressed and distressed.

In the past it was very common for a GP to live in the practice area but today many GPs prefer to live some distance away.

Dr Sarah Humphery

'Offer to let her see another doctor'

I would start by saying I'd been at the surgery a while and explain I was using my maiden name. I would say I was happy to continue to see her, but understood if she felt uncomfortable.

I would emphasise the consultation was confidential but would offer her the option of seeing another doctor.

It would be important to avoid jumping to conclusions before talking to her and assessing the situation.

I would want to give her a chance to talk and would therefore use open questions. I would obviously ask how she got the black eye. Her response would direct the consultation.

I would need to screen for domestic violence and to establish if it had happened before. If there were concerns of violence, her children could be at risk.

I would ask about depression and alcohol and drug use (hers or her husband's). Is there another man/woman involved? You can't assume the black eye was from the husband.

If she seemed willing to talk I would want to find out more about her relationship with her husband. Are there sexual problems, difficulty with the kids or other issues? If I suspected domestic violence and felt it was the right time to discuss this I would give Sharon details of the local women's refuge and other support groups. I would suggest she contact the police, as the violence may happen again.

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