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Is woman's prescription request purely cosmetic?

Julie is a

52-year-old who recently joined the practice. Her presenting complaint is low back pain, for which she wishes to continue taking anti-inflammatory tablets. She asks you to add moisturiser while

you are doing the prescription. There

is no record of a skin problem in her notes but she explains

that she uses E45

to keep her skin youthful and her last doctor always used

to give it to her.

Dr Richard Stokell advises.

How does this request make you feel?

After five years at medical school and three years-plus of hospital medicine, providing anti-wrinkle cream to an over-demanding patient may seem irritating. Is this what the NHS is for?

You may feel justified in feeling angry when the patient fails to follow the traditional pattern: that is, she arrives with an illness, you diagnose it, you give her treatment then she thanks you and goes away. However, variation from this is the norm in primary care, where patients often have no illness, self-diagnose and either don't want or won't take your treatment. Then they save some unrelated problems to bring up after their allotted time.

Why does this patient feel she should have this prescription?

Whatever the reason for her originally using E45, it has been given repeatedly before, reinforcing the patient's belief that it is justified. Asking 'Can you remember why the doctor gave you this in the first place?' may reveal useful information. If there was a specific problem, has it troubled her recently? These questions may guide her to a realisation that there is no continuing medical need for the treatment.

What are the management options?

lPrescribe as requested

lSuggest the patient buys the cream over the counter

lEmploy compromise positions such as saying 'just this once' or prescribing only a small quantity.

We need to consider the costs of agreeing to the prescription against the potential effects that refusal may have on the doctor-patient relationship.

The costs include the possible recurring cost of the drug, the time involved in prescribing the drug, the effects on your morale and the potential for other patients to adopt the same approach.

Refusing may upset the patient as she is used to receiving her E45 and she may even wish to see another doctor on the next occasion. As a registrar you are vulnerable to both manipulation by patients and criticism if your approach is out of line with your colleagues'.

How can you negotiate successfully with this patient?

Reaching a successful outcome depends upon avoiding direct disagreement and trying to 'gift-wrap' your advice to make it more attractive. I would start with a positive stroke such as 'I think it's an excellent idea to moisturise your skin to keep it healthy'. I would also suggest using a moisturiser with sun protection on the sun-exposed areas. I would then float the idea that because everyone should be doing this it isn't possible to provide these things on prescription, but they are available to buy.

If these words fall on stony ground I would consider giving her a small supply on a one-off basis. Sometimes people won't agree with you at the time but will go away and think about it.

Can practice policies be set up for these situations?

Similar problems can arise with a number of other prescription requests. An agreed practice policy provides support to individual doctors and it reduces the risk of doctor-shopping in a practice. Examples of drugs that may be discouraged are nappy creams and moisturisers, paracetamol suspension, topical anti-inflammatories, and cough medicines.

All are available over the counter at pharmacies but also have an important role in the management of some illnesses. This makes an outright ban inappropriate, but practices can still limit their use to very specific situations. For example, paracetamol suspension can be prescribed for a febrile child seen in the surgery but would not normally be prescribed to take on holiday. Creams are readily prescribed to treat nappy rash but not for routine use to prevent it.

Training practices should have a drug formulary and this sort of advice is often included in it. But a policy can only provide guidance and sometimes you just have to decide for yourself.

Key points

lAvoid direct disagreement

lTry to 'gift-wrap' advice to make it more attractive

lAn agreed practice policy will help

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