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Is patient 'stalking' our assistant?

Case history

Natalie lives alone, is quite socially isolated, and is highly eccentric with some sort of borderline learning difficulty. For several years she has sent two- or three-page letters in pencil at regular intervals to your assistant, complaining about various aspects of her life and medical care (the complaints are getting odder and are largely imaginary). Your assistant is a kindly soul and tries to reply to each letter. He is clearly giving a lot of support to this needy patient, who you and your other partners do not wish to see. When you took advice from your protection society, they advised that you should take any complaining letter seriously, however bizarre it may seem.

However, the letters are now arriving most weeks and are becoming increasingly demanding and resentful, asking for help with grants to which she is not entitled and complaining about a variety of non-medical matters. You wonder whether your colleague is being harassed ­ or even stalked ­ by Natalie.

What is the best course of action now?

Dr Helen Joesbury

'The doctors should

agree on a policy for dealing with Natalie'

We have an unspoken contract with our patients. They bring their problems to us and, after some clarification and negotiation, we offer our best advice and they more or less follow it.

Unfortunately, Natalie is not following the 'rules' so her doctor becomes disconcerted and may feel threatened. By trying to please the patient he has unwittingly aggravated the problem of her unreasonable demands and expectations.

The assistant should not be left to handle the situation alone. Although the partners may not wish to be involved, all the doctors should agree on a policy for dealing with her and at least one or two of them should help with the day-to-day responsibility for her. The whole situation is a significant event and should be documented as such.

We cannot tell if Natalie is insensitive, malicious or just unreasonable, but there is a real risk that she will eventually make a serious allegation, especially if she feels the doctor has rejected her. Good contemporaneous records are the best defence against a subsequent complaint.

It may be difficult for the assistant to entirely avoid seeing her again, but it is preferable for her to be seen by another doctor from now on.

They should clearly define the boundaries of what she can and cannot expect from the practice.

She might like a list of other agencies that would be more appropriate to help her with

non-medical problems.

On no account should she be allowed to consult with the assistant outside normal surgery hours and he may consider having a chaperone when he does see her. Unsolicited phone calls should be directed to the on-call doctor and home visits should be discouraged.

The practice manager should respond to her complaints but it is fruitless to spend a lot of energy investigating them in detail, especially when they arise from unrealistic expectations.

Removing Natalie from the list is an attractive option but is unlikely to prevent her causing trouble.

If stalking is a serious concern, the police may have to be involved but it would be so much better for everyone if the problem could be managed successfully by the practice team.

Dr Kashaf Aziz

'I would like to break this repetitive cycle for Natalie's sake and also for my sanity'

This seems like a difficult situation to deal with ­ a patient with a serial complaints syndrome compounded by a learning difficulty.

The learning difficulty may be present in isolation or may exist with other disabilities. Have these disabilities been addressed, or not taken seriously because of the history of the patient?

Key features in her case that need to be addressed are: socially isolated, learning difficulty, not happy with various aspects of her life and her medical care.

This clinical scenario seems to have a large social flavour that needs to be remedied. Medicolegally, we are obliged to respond to all complaints.

Acknowledgement within two days of receiving a complaint, and then a response within 10 days ­ as required by the protection societies ­ is not always a realistic timescale. Natalie seems to be preoccupied with writing her complaint for which she gets a response and attention from my assistant. She seems to be thriving on these responses and her letters are getting more demanding.

I would like to try to break this repetitive cycle, not only for Natalie's sake but also for my sanity. Not only does it use up practice resources but also adds to my stress levels.

One approach would be to invite Natalie to the surgery, perhaps block out an adequate chunk of time to deal with most of the issues.

I would like to try to get into her psyche and try to find out what her agenda or her concerns are. If she is socially isolated, writing the letters may provide her with the only social contact she gets, which perpetuates her behaviour. She may benefit from day centre groups where she will make new friends and be involved in other activities.

If she has family, it may be an idea if Natalie consents to invite them also because they may provide me with extra facets of information and may be my ally in the long-term.

I would contact other community services, perhaps the district handicap team. An assessment should be made to identify her special needs, housing requirements and whether she could take up employment.

A happier, employed and occupied Natalie may result in a 'quieter' Natalie.

Dr Patrick Clarke

'I need to find out if she has a hidden agenda'

Natalie is clearly a demanding patient and it seems all too frequent that a minority of our patients can take up so much time. It may be that she has some hidden agenda we need to get to the bottom of.

I would first of all talk it through with my assistant to see if he wants me to get involved. I would then ask him to give me a summary of the nature of her problems to date. We should review her notes to see if there are any clues to the reason for this behaviour or examples of similar episodes in the past.

We would write to her asking her to come to the surgery to try to help her. If possible, I would encourage her to bring a next of kin or friend. As there have been numerous complaints I would ideally like to have the practice manager present but would want to be careful not to make her feel intimidated. During this meeting, I would want to establish if there are any physical problems and deal with these.

She clearly needs some support but our practice is not able to keep pace with her demands. A community psychiatric nurse may be able to help if there are concerns with her mental health. A social worker may well be able to support her otherwise.

I would prefer not to feel threatened by her letters but careful documentation is required. It may be as well to give my colleague a rest from the patient and see if someone else will take her on.

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