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At the heart of general practice since 1960

Is lonely patient getting clingy?

Case history

Miss Smith is in her late 20s and joined your list a couple of years ago. She always asks to see you for her minor medical problems. She is pleasant, but lacking in self-confidence; she works in an office and has had one serious relationship.

She has confided in you that she feels shy at work and, socially, has one or two friends to whom she is not close, and rarely goes out. She lives alone and worries she will never meet anyone special. She is unfailingly polite, almost deferential and always appreciative of your time.

You recently noticed she is consulting more frequently, asking your opinion on life decisions ­ even whether she should buy a flat. She tells you how she values your advice. Although you were initially pleased that you could help, you wonder if she has started to see you as a confidante/friend/parent rather than a doctor ­ or even something more.

Dr Elizabeth Scott

'Get the practice nurse in to be a chaperone'

This is the time to ask the practice nurse to act as a chaperone. 'I hope you don't mind Sister helping in my surgery. She assists me with injections and examinations.' Any demur can be countered with a phrase like 'It is now practice policy, I'm afraid'.

After two years, the thought that Miss Smith has been gaining confidence in me so that she can disclose some horrendous medical secret such as 'I have this huge lump here', or 'I want an abortion' is a non-starter.

I have had time to decide whether she is heading for a depressive psychosis or if she has a personality problem that needs referral. Any tests I have done have been normal.

Does she no longer see me as her doctor? Having the nurse in the room will remind her she is attending a medical specialist about her health, not her Auntie Jeannie for tea. I would say something like: 'I can only be your doctor, not your life coach. I can think of no further tests or investigations that might help, but in case I am missing something, I have asked my partner if she would see you if you have further problems.'

I would then offer her a list of caring organisations she might like to join, such as the local church, and groups with interests similar to her stated ones. She may leave in a huff. She may create a scene. But with only the practice nurse to turn to, she will get the message.

Should she write to the health authority with spurious claims about my conduct, I would send my explanation to them after consulting my defence union. This is where good notes are indispensible.

Years ago I saw a patient complaining of watering eyes. I examined them and found no abnormality. He returned in a week with the same complaint and I anxiously repeated a thorough examination and really could find nothing. He thanked me for my thoroughness and said he felt relieved that there was nothing obvious and suggested 'Pop in for coffee any time you're passing'.

Surprised, I murmured that I had never had time to pop in to see patients socially. He left and I thought nothing more of it. Then the phone calls started. Night calls at all hours followed by heavy breathing. I and my young family were woken about three or four times a week for three years. It was before callers could be traced easily. The police could not help. The phone company would only put an intercept on for two weeks at infrequent intervals.

I put up with it until he spoke. He had an accent I remembered, so when he said 'When my sleeping pills don't work I ring you, Doctor ­ I like to hear your voice', the penny dropped.

'I never gave you sleeping pills, Mr Jones,' I ground out. 'I'm not with your practice any more. Please don't call me again.'

Three years of insomnia from a man who was not even on my list! Next day I traced his doctor and begged for help and my persecutor was encouraged to see a psychiatrist. 'He was very fixated on you,' said the psychiatrist. 'What did you do?'

'I looked at his eyes on two occasions. There was nothing wrong with them, I told him so and refused his invitation to coffee.'

'A chaperone might have helped,' he said. He was right too. It is too late when you realise you need one.

Elizabeth Scott is a GP in private practice, interested in problems of sleep

Dr Alexander Williams

'I would talk to my wife ­ so she doesn't hear about it as gossip'

This situation has the potential to go very badly wrong unless dealt with by tact and sensitivity. Things could be easily misinterpreted, so accurate and contemporaneous notes will be essential, even recording discussions and advice from others.

As a starting point I would discuss it with my spouse as the last thing needed is for her to find out about things from gossip, which is likely in small communities. Apart from anything else she could give the feminine perspective.

I would also talk to the other partners, the practice manager and the receptionists to see if they have useful insights. They often do, as patients portray their worst characteristics to this unloved workforce. It would be worth a careful review of her notes and contacting previous surgeries to see if there is a pattern of behaviour emerging. It would be prudent to discuss the situation with my defence body.

I would meet the patient but would ask for a chaperone, to corroborate anything that was said and help prevent misinterpretation. Perhaps a letter and a phone call inviting her to a discussion about events would be appropriate, probably at the end of a surgery. I would want to explore her feelings about what has been happening and explain the difficulties this may be causing.

Most likely she will be aware of what is happening and would be amenable to change to another partner's list, or to another practice completely. If she is not able to accept there is a problem the ultimate sanction may be to remove her from your list. However this may open up the agenda of bitterness and resentment and lead to recriminations and possible complaints.

Alexander Williams is lead trainer at his practice in Exeter ­ he is currently on a six-month sabbatical in New Zealand

Dr Rodger Charlton

'What if she has a hidden agenda and I just give her a rejection?'

This dilemma questions the role of a family doctor. It is difficult to differentiate between the physical, psychological and social which some consultation models refer to as the 'triple diagnosis'. One of the questions I ask new students is: 'What is the difference between a disease and an illness?'

They always look bemused, but the answer depends on one's definition of health. The WHO definition is a state of complete physical, mental and social well-being, not merely the absence of disease. Can you turn this patient away?

Perhaps she has a hidden agenda and is seeking the right moment to tell you what is really worrying her. If you reject her (eg, asking a partner to see her) and you are her only confidante, this action may be destructive. This person is presenting a part of general practice you are not taught at medical school. It is an area of patient-centred care that cannot be measured and does not meet targets or quality indicators. As the continuity and personal nature of GPs' care continues to be eroded, such situations will possibly soon not arise.

It is certainly appropriate to consider whether your role is changing from that of doctor to friend or parent. But some GPs may argue that after a time and multiple consultations a relationship of trust develops and without realising you have become a confidante and friend as well as a physician.

Has the relationship become something more than all of this? I think not. As a GP for 18 years I have never felt such a risk developing and feel confident I would notice if it were. I would certainly guard against it and the GMC would expect nothing less!

Rodger Charlton is a GP in Solihull

Learning checklist

Dependent patients

  • This group of patients was identified as a subgroup of 'hateful' patients by Groves in 1978 and called 'dependent clingers'
  • Their main characteristics are frequent consultations, with excessive gratitude for the attention you give and an inability to recognise the negative feelings they engender within the doctor
  • Tend to present poorly defined problems
  • They consistently fail to take responsibility for decisions in their lives, choosing instead to let the doctor do this
  • Often represent a problem with the doctor-patient relationship, with a failure to communicate effectively, recognise the complex reasons for their attendance and the meaning of the illness to the patient

Strategies for the doctor

  • Try to recognise the psychosocial aspects of the patient's illness
  • Use listening skills to uncover the patient's hidden agenda
  • Recognise your own emotional response to the patient
  • Consider setting rules to patient contact such as planned review periods
  • Try to avoid investigations and referrals and prescribe conservatively; instead encourage them to make their own decisions as an adult
  • Reflect on consultations afterwards, perhaps with colleagues

Transference

  • Sometimes patients can confuse your compassion and their gratitude with love; this can result in misinterpretation of verbal and non-verbal cues
  • Physical contact during examination can also be interpreted as sexual contact
  • This is not exclusively a problem for male doctors with female patients

The options available if this problem is suspected are:

1) Discuss the issue with the patient and continue seeing them, provided proper boundaries can be kept to

2) Involve a third party as a chaperone

3) Arrange for the patient to be seen by another doctor

All courses of action could result in a complaint and record keeping is very important.

Use of chaperones

  • Our best defence against being complained against is to develop a good relationship with our patients
  • Communicating well, examining sensitively after explanation and gaining consent are important aspects of this
  • Look for the patient's body language and listen for verbal cues to assess their understanding and willingness to undergo an examination
  • There are no rules for using chaperones but keeping records where they are offered and accepted and considering the wisdom of proceeding with an examination where one is refused are important issues
  • How has your chaperone been trained?
  • What are the confidentiality issues of a chaperone being present in the room?

De Clerambault's syndrome

  • Very rarely, a doctor can become the victim of this syndrome in which a patient develops a delusion that he or she is in love with the
  • There is often only the slightest acquaintance between victim and patient
  • Embarrassing and sometimes frightening advances start happening
  • Attempts to ignore or stop these intrusions are interpreted as suppression of the victim's 'true' feelings or an inability to show their love for other reasons
  • These patients require psychiatric evaluation as there is a real threat posed by these patients to their victims
  • Read Enduring Love by Ian McEwan or see the film to gain a better insight into the syndrome

Richard Stokell in a GP in Birkenhead, Merseyside

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