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Patient with chest pain delays his appointment in order to see you

Three GPs share their approach to a practice problem

Case history

You always like seeing Mr Smith, an elderly man with angina and COPD, who doesn't bother you much, but makes you feel appreciated in these days of 'dial-a-pizza' patient expectations. You are pleased to see his name on your list this morning, but alarmed to discover he is in heart failure. In fact he suffered several hours' central chest pain five days ago, and has probably had a myocardial infarction.

When you ask why he didn't call for help immediately, he tells you he did but because of advanced access he was offered an appointment with a doctor whom he didn't know. He says he preferred to wait to see you 'because you know me, doctor'.

Dr Sian Howell

'I would express my confidence

in my colleagues at the practice'

Having assessed him clinically and initiated treatment and referral, I'd talk to him about the delay in diagnosis.

I'd explain the delay in seeing him might have made a difference to his heart function and that if he tells reception staff he needs to be seen urgently they will always arrange a same-day contact with one of the doctors or nurses.

I'd express my confidence in my colleagues at the practice and ask that he sees them for new or urgent problems in the future, if I am not available that day. I'd explain they would always arrange follow-up care with me and would clearly document all his treatment in his records.

I'd ask him if there is anything he thinks we could do as a practice to improve how we see people with urgent problems. Was it only that he wanted to wait and see me, or was there anything else in our system that made it difficult for him to be seen straightaway?

I'd then include this at the next full practice critical event meeting. I'd ask reception staff, nurses and GPs whether they thought this was an isolated case or part of a pattern.

We'd need to revisit how we all inform patients about accessing emergency care both in and out of hours, look again at the advice reception staff give and ensure we are all following practice protocols on dealing with emergencies.

We might need to change our practice leaflet or put up posters in the waiting room giving advice on when and how to see a doctor urgently.

Perhaps advice on accessing emergency care should be given specifically at the initial registration appointment and at over-75 checks, with a computer prompt added to the relevant template.

Sian Howell completed the VTS in 1996 and is now a partner and lead undergraduate teacher at her practice in east London

Dr Melanie Wynne-Jones

'I wouldn't like to think that I had encouraged dependency'

The 'window' for acutely admitting Mr Smith for his MI is long gone, but I would start with a clinical assessment; he may be in atrial fibrillation or sufficiently severe heart failure to warrant admission. I would take a history of the past two weeks, examine him, check his full blood count and U&Es if these had not been done recently, and arrange an ECG.

Because he has angina and we aspire to 100 per cent quality and outcome points under the new contract, he should already be on aspirin, with his cholesterol level under 5mmol/l either naturally or as the result of a statin.

Depending on my findings I would start him on ramipril and a diuretic, advise him about activity and driving, and arrange to review him in a day or two. Because he has COPD rather than asthma I may prescribe a ß-blocker, but I am cautious about introducing too many drugs simultaneously because it can be difficult to disentangle adverse effects. I would also contact the cardiac rehabilitation service.

This is a significant event. Mr Smith should have known to call the practice or dial 999 because his chest pain wasn't relieved by GTN after 15 minutes. I would check whether he had been told this, whether he had remembered the advice and, if so, why he had not acted.

Mr Smith comes from a generation used to having 'their' doctor, and which tends to think twice before calling the doctor, even for serious problems.

It's nice to feel appreciated, but I would reflect on my relationship with Mr Smith. I wouldn't like to think that I had encouraged dependency, or got too cosy at the expense of clinical imperatives.

Melanie Wynne-Jones has been a GP for 20 years and is a GP trainer and appraiser in Marple, Cheshire

Dr Chris Hall

'It's important to establish the facts before confronting valued staff'

It seems advanced access has failed to deliver its raison d'être – to allow those with urgent medical problems to be seen within an appropriate time. Clearly Mr Smith had an urgent and appropriate medical problem; the key question is whether our systems failed to detect that his problem was urgent.

Let's not jump to conclusions. Perhaps Mr Smith understated his symptoms or didn't articulate their urgent nature. Who triaged his call for help, if it was triaged at all? It's important to establish the facts before, for example, confronting a valued member of staff. Rather than apportioning individual blame at an early stage, we should review our systems and procedures. It seems likely, though, that early intervention would have improved his outcome.

As ever, it's prudent to document everything carefully. Mr Smith's family may take a different view of things in time. Patients and families often forgive for missing a diagnosis, but less often for failing to examine at all. Hopefully we have documented that Mr Smith was, in fact, offered an appointment.

A confirmatory ECG and cardiac enzymes would now seem sensible, as is ensuring the most appropriate and timely follow-up, including

optimising his medication post-infarction (if appropriate) and an early echocardiogram. Clearly Mr Smith has responsibilities as well as rights, and I would explain to him that in the event of an urgent situation, such as unresolving chest pain, it's not essential to see a specific doctor, rather it is early treatment that is paramount. Hopefully this will strengthen, rather than erode, his confidence in the practice.

This would seem an appropriate case for a critical event analysis, as well as an opportunity to formulate new practice protocols for advanced access.

Chris Hall completed the VTS in 1999 and is now a partner in Belfast

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