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Gold, incentives and meh

Patient's GP father writes letter criticising your treatment

Case history

A 35-year-old married patient arrives with a letter from her father, a retired GP. In the letter he says he is not happy with your management of her depression and wants her tablets changed. He says they are not strong enough and you should double her dose and refer to a psychiatrist. He mentions the name of a psychiatrist who has long since retired who he recommends. He adds that he hopes you will follow his 'reasonable' recommendation.

You bite your lip and ask how the patient feels. She bursts into tears, saying it's your fault she is badly depressed. If you had treated her properly, she would be a lot better by now.

Dr Elizabeth Scott

'She may just be manipulative or she may be becoming acute'

'I am so sorry you feel like that,' would be my response, because I would certainly have referred her to a psychiatrist when starting her on medication. If she had not understood that at the time, I hope being reassured that she is going to see a specialist will comfort her.

I would offer her the tissues and let her talk. I might ask her to write everything down and make a double appointment for the next day. I would invite her to bring her husband if she wished, because those nearest to her are likely to be a useful guide to mood change. She would have completed a depression checklist when she first attended and I would ask her to complete another.

This would show if a real change in symptoms has occured (she may just be manipulative, but she may be becoming acute). Before she went home I would enquire about suicidal ideation and write her reply into her notes. If self-harm seemed a real risk, I would ring the psychiatrist on call. Given these further inputs, I would make up my mind whether she needed a change of medication or dosage as suggested by her father, and I would record her views on this as well. She could have registered with another doctor but hasn't, so she and her father seem to wish me to continue her care.

I would ask her permission to ring her father and discuss her case, and thank him for his interest. It is essential to make him and his daughter feel I am taking her seriously. Having told the father to whom I had referred his daughter, I would mention that his choice was retired and give him a time when he can reach me by phone. Should she refuse, I would write to him, thank for his letter and care, assure him of my best efforts and tell him his daughter had refused permission to discuss her case.

Elizabeth Scott is a GP in private practice, interested in problems of sleep ­ she serves on disability tribunals and writes for medical magazines

Dr Mabel Aghadiuno

'Has something happened that has alarmed her dad, such as a suicide attempt?'

Many issues flash through my mind as I read the letter. Instead of being indignant, I would have to question if there is anything I can learn. The patient and her father have doubts about my management of the case.

This is an opportunity for me to review it. Is depression really the problem and does the patient have its clinical features? Does she need antidepressants or would psychological therapies be more appropriate? She has blamed me for her lack of progress. Has she been frank with me about her history?

Has something occurred that alarmed her father such as a suicide attempt? Why does she think the antidepressants are not helping her and what are her expectations of medication? Are there any other issues that may be affecting her mental health? Her father advises an increase in the antidepressant dose and referral to a psychiatrist.

I would like to establish if this is truly necessary. Is there a risk of suicide or are psychotic features present? Is the current medication at an optimal dose or does she need a change? Has she already tried another drug to which she was equally unresponsive?

It is only courtesy to respond to the GP, who is ultimately an anxious parent. I would, however, write a general letter that does not reveal any details of the case. I would also invite him to give his reasons for suggesting referral. After all, he may know things about his daughter that I do not. I am the clinician with overall responsibility so if she is insisting on a private referral I would have to be satisfied about the expertise of the specialist. Her father recommends a psychiatrist who has long retired.

Is he registered with the GMC and a member of a defence union? If I had any doubts about the level of his competence I would not refer the patient to him but suggest alternatives. Finally, choosing how much information she gives to her father is the patient's prerogative and I have to respect this. I also have to respect confidentiality. I leave it up to her to communicate the details of her case to her father if she wishes.

Mabel Aghadiuno is a part-time sessional GP at Croydon PCT ­ she is on the specialist register of the Faculty of Homoeopathy and practises homeopathic medicine both on the NHS and privately

Dr Keli Thorsteinsson

'He's probably a little man trying to make himself look bigger in the eyes of his daughter'

It's difficult to be angry with the patient. I'm basically a nice guy and giving patients the benefit of the doubt is in my nature.

I will assume that this lady is still depressed and undertreated. Her words and manner suggest her father used stronger words about her alleged mismanagement than are contained in his letter.

I will be quietly irritated and surprised at him for undermining me like this. If he's so unimpressed with me, why didn't he tell his daughter to see someone else? I suspect he knows full well that, for all practical purposes, there is no secondary care provision under the NHS for mental health problems unless patients are discovered attempting suicide.

He must know that most GPs do an amazing job despite this. So, he's probably a little man trying to make himself look bigger in the eyes of his daughter. Perhaps his failure as a person or a parent is partly to blame for her state, who knows?

I am tempted to do as he suggests and refer her to this retired psychiatrist but that would achieve nothing. No, I won't stoop to the father's level and will act professionally, listen to the patient, etc. I've yet to meet a patient who doesn't calm down if I listen and am respectful.

Once she has calmed down and we can have a sensible conversation I will offer her a referral to the community psychiatrist. I will mark it urgent and fax it, if that is allowed.

Of course nothing will happen or the psychiatrist may ring me later in the week suggesting I refer to the CMHT (of which he/she is the lead clinician and who only see patients who attempt suicide), counselling (eight-12-month wait) or cognitive behavious therapy (no local provision). Then I will have to ring the patient and tell her the only help available is me and an SSRI, unless she wants me to refer her privately. Then I wait for her dad to call.

Keli Thorsteinsson is a GP in Shrewsbury

Learning checklist

Caring for the depressed patient

  • What should the initial assessment of a depressed patient cover? This will be included in the QOF from April 20061.·
  • What are the indications for and arguments for and against medication (including St John's wort), counselling, psychological therapy, psychiatric referral and self-help strategies?2
  • How are psychiatric services organised and resourced in your area? How would you manage a patient expressing suicidal ideas?
  • How often should depressed patients be monitored, and what should be covered at each review? What factors might suggest a change of treatment?

Third party involvement

  • Why do third parties get involved? Are they expressing dissatisfaction or concern, or interfering? Do they have additional information the patient has concealed or doesn't consider relevant or are they acting on misinformation or inadequate information?
  • Are they participating with the patient's knowledge and uncoerced consent? What do you do if they forbid you to tell the patient they have contacted you?
  • When might patients involve a third party? If a patient brings someone in with them, what is the significance?
  • What are the potential benefits and disadvantages?
  • What special challenges are posed by third parties with medical expertise? How should we deal with them? The GMC says you should, wherever possible, seek independent and objective medical advice whenever you, or someone with whom you have a close relationship, require it3. How should we react to these letters?
  • Does the patient agree or disagree with her father? Why didn't/couldn't she tell you herself?
  • Should you do/have done anything differently?
  • Reflect on this event and if necessary discuss it with colleagues. Is this something for your appraisal folder?

Professional responsibilities

  • There is no compulsory retirement age for GPs or for consultants doing private work after NHS retirement. How do retired doctors keep up to date? Doctors cannot work after retirement unless registered with the GMC; there are plans to prevent doctors from prescribing for themselves or their families if they do not revalidate
  • Can you actually stop your patient from consulting the retired psychiatrist?
  • How do we recognise the dissatisfied patient? What are the causes of dissatisfaction and how do we cope? Is this a complaint? How does the complaints procedure operate?

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