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Natural to be sceptical

Three GPs share their approach to a practice problem

When different patients need a doctor ­ now!

Case history

You are doing the late surgery and are the only doctor available. There are already four 'extras' waiting to see you. A Mrs Smith rings in demanding an urgent visit for a feverish child, Jane, who is vomiting and has a temperature. Mrs Smith says she can't possibly bring Jane in as she herself has injured her back, and no responsible adult will be available to bring Jane to the surgery in the next hour. She demands that you visit at once, and in the interests of the child (and of avoiding a complaint) you drive through rush-hour traffic to find Jane is not well, but not that ill either.

Back at the surgery, your receptionist has called an ambulance for one of the extras who has collapsed with chest pain; the patient's wife was apparently distraught that there was no doctor on the premises. The receptionist says the patient looked terrible, and needed oxygen before the ambulance could take him to A&E.

Dr Helen Joesbury

'The event warrants discussion with all practice staff and may lead to changes'

The juggling of priorities is a perennial problem of general practice and I guess most GPs will have had an incident like this. When a worried parent asks for an urgent visit it is difficult to refuse, especially when the symptoms could stack up to something serious like meningitis.

Before rushing out in the middle of surgery I would always tell the patients in the waiting room why I was leaving and offer them the choice of staying till I get back or rebooking. Inevitably they will be inconvenienced and it is courteous to keep them informed.

A particularly ill patient might then ask for earlier attention but most patients are willing to stand aside for an emergency.

After I had examined Jane and excluded an emergency diagnosis I would tell her mother quite firmly that by calling me out urgently she had taken priority over patients who might be more ill. She may understand little about common childhood symptoms, so some advice could prevent another 'urgent' call.

While general practice is available for acute illness, it is not designed to be an emergency service and cannot compete with paramedics responding to a 999 call. The receptionist did the right thing in calling for assistance and should be reassured. While expressing my regret at having not been immediately available, I would explain to the patient's wife that the paramedics were especially skilled in dealing with this situation.

This whole incident is a significant event. It warrants a full discussion by the practice team and may lead to changes. All practice staff should be confident they are up to date and have the necessary equipment for resuscitation.

Perhaps there could be more clinical staff routinely available during surgery hours. And the practice leaflet might be used to educate patients about emergency care.

Helen Joesbury is a GP in Sheffield, part-time senior lecturer at the University of Sheffield, and a GP adviser to the Department of Health

Dr Lucy Free

'The doctor deserves this ­ you can't be all things to all people'

This ridiculous scenario is entirely of this GP's own making. If you have a need to be all things to all people and a fear of being complained about, then you deserve to find yourself at sea. Has he not heard that the road to hell is paved with good intentions?

This ludicrous 'advanced access' system merely enables potentially self-limiting minor conditions to be seen at the expense of more significant illness, and the cluttering-up of additional appointment slots with other reviews and checks seems to have further decreased the time available for people who are actually ill to visit their doctor.

However, one would have to question the practice arrangements that have led to such an inefficient and ineffectual use of resources, and why the principle of triage 'to do the most for the most' was not applied. Did this GP just make one bad decision, or is the whole set-up an accident waiting to happen?

This practice needs to closely examine its resources and systems to ensure the staff are not exposed in this fashion again. They need to look at the number of available appointments versus the demand, and the provision for 'extras', and probably institute some sort of nurse or telephone triage system to filter the patient's concept of an emergency situation.

Short-term this doctor needs to be philosophical about what has happened. He needs to finish evening surgery and then to visit the hospital to check on the progress of the collapsed patient. In the medium-term the practice must look at its procedures for emergencies within the premises, including drug protocols, expiry dates, and information cascades. And in the long-term the partners must examine the ethos of the practice to ensure that sanity is not sacrificed for the sake of the bank balance.

Lucy Free qualified more than 20 years ago and is a GP in Hurstpierpoint, West Sussex

Dr Prashini Naidoo

'I need to maintain my relationship with both of the patients'

The first step is to attend to my feelings and to wait for the strong emotions to dissipate before I act. I probably feel scared that my decision-making delayed the treatment of a possible MI, and if so, self-doubt and vulnerability will rear its head. At the same time, feelings of dislike for the manipulative and demanding Mrs Smith will make me feel angry and defensive, and it will be easy to shift all blame on to Mrs Smith. I need to avoid doing this if I am to learn from the situation.

For me, there are two learning points: first, do I know how to triage, and second, can I be assertive? Telephone triage is notoriously difficult and without the visual cues, I imagine the worst. I am also sometimes guilty of not triaging. If I was caught by Mrs Smith's demand in the midst of a very busy clinic, and was under enormous time-pressures, I probably took her assessment of her child at face value, mentally having resigned myself to pushy, complaining patients.

I am not proud of this reflexive reaction, and in future I would be a better doctor if I triage first by ascertaining answers to 'red flag' questions, and then debate on the merits of a visit. Part of my motivation to visit was the perceived threat of a complaint. I need to be assertive to avoid being bullied into making poor clinical decisions.

I need to maintain my relationship with both patients. With Mrs Smith, I need to avoid sub-consciously punishing her in the future. With the patient with chest pain, I need to be proactive in finding out what happened.

The patient may be feeling let down by me, and an explanation of what happened with a discussion of what may be improved, may repair the relationship.

Prashini Naidoo completed the VTS in August 2002 and is a salaried GP in south Oxfordshire ­ she recently completed a diploma in occupational medicine and is studying towards a Masters in primary care development

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