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Pneumococcal vaccine's benefit

The dragon at the gate who denies access to the doctor, dispensing medical advice and even prescriptions, is every GP's nightmare.

But jumping to conclusions here could be risky. It's quite possible that this patient has been assessed at the hospital, at home, or even in the surgery, and that senna has been recommended.

He may have phoned to pass this information on to his usual doctor, something many patients like to do, or simply to check whether a prescription is needed (although if he was eligible for free prescriptions, he could now have cause for complaint).

The receptionist may have been trying to show empathy and support, although relating her own history was probably excessive, and phone calls like this should be concise.

On the other hand, if she is really giving out advice to a patient who could be in the throes of post-operative complications, this clearly carries huge risks. The patient may be falsely reassured, take inappropriate medication or be denied medical advice.

The partners would be vicariously liable for the receptionist's actions. If you discover that other receptionists also do this, or that your partner condones such behaviour, you have an even bigger problem on your hands.

It's important not to shoot from the hip, as implying immediately that the receptionist is at fault may have all sorts of consequences. Asking about the background to the phone call should quickly reveal whe-ther your concerns are justified; you may need to contact the patient yourself.

Later you will need to speak to your partners and practice manager, and discuss whether retraining or disciplinary action would be appropriate.

What are the risks in this situation?

Should doctors and other health professionals reveal personal information to patients?

What should be said to the receptionist?

What other issues does this raise?

This situation poses two dilemmas: first, a receptionist giving medical advice, and second, a patient with a serious post-operative condition being given incorrect advice.

The receptionist is trying to be helpful but has gone well beyond her remit. This needs to be managed in a diplomatic way. It is important that she is made aware of her inappropriate action but in an inoffensive way and so that she understands when a patient needs to speak to a doctor.

As a GP you are responsible for the actions of the employed staff and so ultimately you will be to blame for incorrect advice. I would encourage this receptionist to keep a list of the problems she has advised patients on and for one of the GPs to review this for the next month to ensure this is not happening in other areas of practice, and to ascertain any other training needs.

The GP should also consider:

·Does this incident reflect what is unwittingly expected of receptionists?

·Does the receptionist feel this is a minor matter for an already work overloaded GP?

·Do the receptionists feel unsupported and so give advice to protect busy GPs in case they display irritation at being disturbed?

· Do the receptionists think they can give good advice and are they working beyond their station?

· Should the practice institute a series of guidelines/algorithms for likely areas where patients seek advice?

· Is this an opportunity for the practice to review its induction package for new staff?

I would also ring the patient and explain that I had been made aware of the receptionist's advice and that I wished to clarify their symptoms, the advice given, the need for a possible abdominal examination and when the patient should seek medical advice.

Triage goes on all the time, in pharmacies, in patient groups, and to a lesser extent within families. Patients are encouraged to seek information from books and the internet, but the norm has become to check with health professionals just in case. The phrase 'it's better to be safe than sorry' litters consultations like a mantra.

What is going on here is a simple form of triage; are these symptoms significant or not? Is the receptionist providing simple triage, or is she overstepping the mark? On the face of it it's difficult to decide; so much depends on the people. Perhaps this is a patient who cries wolf, and a well- trained receptionist with common-sense is worth her weight in gold.

Senna tablets are available OTC, as are any number of other drugs, and they are readily available, with provisos in the instruct-

ions, because they do more good than harm.

We expect patients to take some responsibility for their health; to try aspirin for a headache, antacids for indigestion, to use ice on sprains. Constipation after bowel surgery is practically par for the course as the body readjusts; it's not unreasonable to try over-the-counter remedies.

The fear, of course, is that this is an obstruction; Crohns's is a complicated and unpleasant condition. There is no mention of vomiting, so the worst that can happen is that the patient won't improve.

If he has been told to phone back, no harm will have been done. Employers are responsible for employees' actions so you need to be confident that they are trained and up to the task, but there is no reason why problems cannot be triaged in this manner, documented and a back-up plan provided.

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