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Patient insists you told her to cancel holiday

Case history

You receive a holiday cancellation form from a 48-year-old woman.

She has cancelled her holiday in Barbados for herself and husband. When you review her notes you find only one relevant entry three days before she was due to fly.

The entry reads 'Sore throat, red fauces, no tonsillitis, systemically well, apyrexial, advice palliate'. There is no mention of a holiday or cancellation.

Three days after completing the form you receive an irate phone call from the woman. She says the insurance company has refused to pay the £3,000 compensation and that if you do not change the form she will expect the practice to pay the money!

She aggressively informs you that you had 'told' her she was too ill to travel and must cancel her holiday.

As a general rule you always document such advice in the notes in case you later get a form to fill in.

Dr Patrick Clarke

'I would tell her that everything that was said is in the notes'

I would check the notes of this patient to see if there was any similar behaviour in the past or any past psychiatric history. I would aim to do my best to resolve the situation and prevent her vandalising the practice or my car!

I would discuss the case with my partners and practice manager before getting back to her as this could affect all of us. I would also contact my defence union to ensure I am not getting into deep water.

When I was ready I would contact the patient and ask her to go through the problems. I would ask if there were any other medical conditions that would have prevented her travelling. She needs to be told that everything that was said or done during her consultation was documented. It would not be normal practice to stop her going on a dream holiday because she had a sore throat. There may be other circumstances that prevented her travelling and they may enable her to get her compensation. While I'm talking to her I can assess her mental state. It may also be worth talking to her partner.

Assuming there are no other reasons why she cancelled her holiday, I let her know it is against my code of practice to lie on such forms. I do try to help my patients so if there was anything I could to help her claim honestly I would do so. It is up to the insurance company whether they will pay her compensation. They may be able to come to some compromise such as paying some of the money back or giving her money off a further holiday.

I do not take kindly to financial threats and would make this clear. In a worst case scenario I would consider removing her from our list. I would document everything that was said, ideally have another partner present and fully inform my defence union.

Dr Claire Pedder

'I won't lose any sleep worrying about what to tell this woman'

There I was thinking it was my job to diagnose disease, support the sick and comfort the dying when all along I should have recognised it was to be an accomplice to insurance fraud.

I don't have to wrestle with my conscience to work out how I fulfil my role as patient advocate in this situation. While I am willing to bust a gut to ensure I robustly represent my patients in times of genuine need, I am not going to lose sleep over this. I did not recommend this woman cancel her holiday on medical grounds, and my record of the consultation indicates there were no medical grounds for this. Feeling a bit under the weather is no reason to cancel a Caribbean holiday ­ in fact I am more likely to suggest it is just what someone with an URTI might need!

Although mistakes do happen I simply would not have failed to document such important information as telling someone they should cancel their holiday. Besides, I rarely dictate what patients should do about holidays ­ just as I do not stand over them at home to ensure they have taken today's medication. I can only provide them with a medical opinion and hope they see the sense in my argument.

So, I would take a deep breath and calmly tell this woman that while I am sorry to hear about her situation, I am unwilling to compromise my probity and as there is no evidence to suggest that I either did, or would have, 'told' her to cancel her expensive holiday, I am not in a position to change her form.

I would then silently chant my Monday morning mantra of 'only 20 more years to go....' while she fumed down the phone, and amuse myself debating the odds on when I will receive a letter from her lawyer.

Dr Lucy Free

'We're supposed to be gatekeepers ­

let's guard the gate'

I would have no truck with this woman. This is a clear attempt to defraud her insurers. To collude with her because of embarrassment or insecurity is wrong.

Doctors are asked to sign documents, prescriptions, requests and certificates because they are expected to behave the correct way, to be sensible and fair, and to do the right thing. They are expected to resist coercion, be impervious to bribery and not to discriminate in any way. To be bullied by this manipulative woman into funding her expensive mistake is unacceptable.

The key to this unpleasant episode, as with so many disputes in general practice, is in the notes. If there had been any intimation that this minor episode would impinge on her holiday in any way, there would have been a record of it. It is inconceivable that such a significant decision could have been made without some record in the notes.

Of course she could have misinterpreted the transaction (or chosen to), but with clear notes I am on safe ground. In realistic terms, she would have to sue for the money, an unlikely scenario.

Notes of course can only record the bare bones of a consultation. A lot more goes on that is untranslatable and unrecordable. Some patients can't cope with being told to take one tablet twice a day until they're finished, so it is no wonder that there is an interpretive discrepancy in a complex interaction like this one. And then there is human nature; if she was the wife of a golfing acquaintance, or simply someone that you had a soft-spot for, it would be easier to be flexible. But she isn't. This is a woman who has made a unilateral decision to take her holiday at a more favourable time and expects to be cushioned from reality by the doctor's rubber stamp.

The decision is yours, but I believe that we are supposed to be gatekeepers, we should therefore guard the gate.

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