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New patient demands monthly home visits

Three GPs discuss a tricky problem

Case history

A 46-year-old woman who is a new patient requests a visit. But she refuses to tell the receptionist the reason why, only saying that it is personal.

When you visit she requests antibiotics for a urinary tract infection (she will not provide a sample of urine claiming that 'she knows her own body'). She also asks for nicotine replacement therapy and a blood test for diabetes.

After these points are dealt with she then requests a routine home visit once a month to check up on her ­ she says she finds it too stressful to attend the surgery and doesn't like the waiting room. Her previous GP would 'pop in' every month when in the area and she would like this to continue. Furthermore, she tells you you will have to work hard to gain her trust as doctors have let her down, failing to diagnose her condition.

A subsequent review of her notes shows extensive investigations for lower back pain and leg weakness, and that no organic pathology has been demonstrated. The last hospital letter mentions onward referral to a psychologist.

Dr Annette Steele

'She needs to understand the way a GP team works'

Even though the patient is entitled to refuse to discuss reasons with the receptionist, this makes prioritising visits difficult, and adds to the GP's workload. However, a telephone call by the GP would have been invaluable, and the patient could have been invited to the surgery instead (working on the assumption that she isn't housebound). This would have been an opportunity to check the notes and get a better feel for the situation before coming face to face with her.

As she is new to the practice, this is a good time to establish boundaries and ground rules. We have a duty to provide clinical care as laid out in the GPC's Good Medical Practice, but the duty to visit in the patient's home is based on clinical need, not convenience or habit. I would explain this gently but firmly and explore her reasons for refusing to attend the surgery.

I would explain the role of the team in modern general practice to her, so she understands that attending the surgery would enable her to access the skills of a multidisciplinary team rather than just the attentions of myself. Her smoking cessation is best dealt with in a structured, possibly nurse-lead clinic, as would her chronic disease screening. She needs to know that GPs do not have enough time for routine home visiting.

I would like to explore the reasons why she left the last practice and to discuss her perception that other doctors have failed to diagnose her condition. If others have failed to find a physical cause for her symptoms, it is unlikely that new GPs will either. Explaining this may help her to move forward and follow the psychological route already recommended rather than going over old ground.

Dr Mark Wallace

'First and foremost I must not jump to any conclusions'

After hearing this woman's description of her previous care I would do well to stop my lower jaw and heart from hitting the floor. I can immediately foresee a very long tortuous road ahead to re-educate her on the most appropriate way to access the very precious resource that is primary care. However, first and foremost I mustn't jump to any conclusions.

As this is our first meeting her requests provide me with a timely opportunity to start the process of

re-education. I certainly wouldn't compromise my clinical standards and would insist on a mid-stream urine sample to assess for UTI. I would ask her why she's concerned about diabetes (it could well be that glycosuria was accounting for her urinary symptoms) and inform her that a urine dipstick was a good screening tool.

It would seem that her reason for not attending the surgery has nothing to do with her 'leg weakness' but rather anxiety. I would strongly urge her to visit our friendly, unintimidating surgery where if necessary she could always be accommodated in a side room if she were to become tense. I'd offer a routine follow-up double appointment in a couple of weeks on the pretext of discussing nicotine replacement therapy but would hope to venture cautiously into psychosocial territory.

If, as I hope, she attends this appointment I would give lots of positive feedback about coming to the surgery. I would feel I had certainly won a moral victory if I managed to persuade her to come to the surgery and would proceed to book her follow-up appointments at appropriate intervals.

In due course when I'd gained her trust I might mention the possibility of a mental health team referral.

I fear the more likely scenario is that she would continue to insist on home visits and my implorings fall on deaf ears. In which case, after asking all and sundry for help about how to change her behaviour, I might have to urge her to change doctor due to the unsustainable burden she places on me.

Dr Kashaf Aziz

'Tackling every problem now will reinforce her behaviour'

Usually I phone-triage patients who request a visit, because trivial problems may be dealt with over the phone. This saves me time and keeps stress levels to a minimum. It seems this patient is used to having her own way and it is time to educate her in the ways of modern, overstretched GP resources.

I would try to elicit from her what her fears are. Is she unable to attend the surgery because she is a sole carer, cannot afford proper transport or has got into the routine of home visits?

At the visit I would ask her to list her two most significant problems and deal with those. I would accompany this with an explanation, in a non-confrontational manner, that 'visits are only for emergencies and patients who are so incapacitated by their illness they are unable to attend practice'.

I would also want to tackle her possible UTI. This might be clinically significant if not dealt with now as it could progress into a pyelonephritis. I would not be too happy about prescribing without a urine specimen to confirm the diagnosis. Again, I would try to educate her as to the reason why a specimen is required. If she were very stubborn, and has a history of UTIs, I might have to provide her with a short course of antibiotics.

I would stand my ground on the nicotine replacement therapy. It is not an appropriate time or place to do this and if I did this would reinforce her behaviour. However, my aim would also be to try to develop a rapport with her and I would suggest she attends the surgery to see me. I would ensure she got the first appointment of my surgery to avoid the 'stressful waiting room'.

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