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At the heart of general practice since 1960

Quality points as a capital asset

Three GPs share their approach to a practice dilemma

Confidentiality issue on 'missed' two-week referral

Case history

Mrs D's daughter, Mrs E, comes to see you. Her mother is in hospital following an emergency admission for stomach pains. Tests have shown she is suffering from bowel cancer. Mrs E has found out about the two-week rule and wants to know why you didn't refer her mother urgently when she came to see you six weeks ago.

Mrs D had actually complained of constipation of a few weeks' duration which coincided with her starting to take a calcium channel blocker. You questioned her carefully about bleeding or mucus, weight loss and so on, but she had no other symptoms at all and abdominal and rectal examination were normal.

You had an uneasy feeling at the time, but couldn't tick any of the boxes on the two-week cancer referral form, so you asked for an 'urgent' opinion instead and told her to come back if she developed any new symptoms in the meantime. Mrs E informs you that her mother's outpatients appointment is still three weeks in the future, and adds that the hospital doctor had expressed surprise that you had not made a two-week referral.

Dr Richard Stokell

'Showing interest may defuse some of the daughter's anger'

My first concern in dealing with the daughter is to maintain patient confidentiality. I would make sure the patient's record was not visible on the computer screen and advise her that I would not be able to discuss any of her mother's specific medical details. Nevertheless I can still listen to the story of how her mother ended up in hospital and what she has been told about her condition.

Listening and showing interest may defuse some of the daughter's anger. I can also get some idea of her perception of her mother's symptoms at the time of presentation. At this stage I can express regret that I wasn't able to reach the diagnosis earlier and suggest that I need to have a look at my own records to see what my findings were when her mother first presented.

If asked I would explain the mechanics of two-week referral guidelines. I would offer to visit her mother either in hospital or as soon as she comes home and suggest that, with her mother's permission, Mrs E could be present.

I would then have a careful look at my notes and try to decide if I could have done things differently. I would present the case as a critical event within the practice. This would ensure any lessons that could be learnt from the case were learnt and it would help me to answer any subsequent questions.

Visiting Mrs D at home would be the most likely next consultation. After getting a progress report and dealing with ongoing problems I would probably tell her how upset I had been to hear of her emergency admission. I would discuss my understanding of her presenting complaint and my findings at the time.

I would talk to her about why I had referred her in the way I had and why I had not used the two-week pathway. I would also perhaps tell her that we looked at the problem of her referral as a practice to see if we could have done anything differently. I would then arrange follow-up and try to re-establish a good doctor-patient relationship.

Finally I have to deal with the stress caused by the case and consider whether I should have taken more notice of my 'uneasy feeling'.

Richard Stokell is a GP in Birkenhead, Merseyside, and a GP trainer and course organiser

Dr Declan Fox

'Shared understanding would be my aim in this situation'

I am of course very limited in what I can say here. This in not the right time to approach Mrs D for permission to discuss her case with Mrs E even though I could defuse the situation simply by producing a copy of my original referral letter, marked 'urgent'. I need to explain confidentiality rules to Mrs E, but first I will express sympathy and best wishes for Mrs D's full recovery.

Having explained confidentiality, I will reassure Mrs D that I expect to answer most of her questions on urgent referral. It would be best to avoid snap judgments of Mrs D's agenda; rather I will try to establish some degree of rapport initially. It would likewise be best to avoid criticism of the hospital doctor whose 'expressed surprise' was more likely an attempt to divert blame away from himself for ignoring my urgent referral. Worse, he may not have read my referral letter at all.

I will explain that the two-week rule is an attempt to cut through waiting lists for patients with suspected cancer. I will show her a blank referral form and point out the authorship ­ ie doctors in my local hospital, not me. I will take her through the tick boxes, tell her about worrying symptoms of bowel cancer while studiously avoiding any reference to her mother's history. Having taken a few minutes on the form, I can then point out that only those patients meeting all the criteria on the form will be seen within two weeks.

In all other cases the form will be returned to me with a letter advising me to make a new referral in the normal way. Once she has studied the form, I will ask her to go through the tick boxes again and tell me if she thinks her mother's symptoms matched up with those on the form.

This part of the consultation needs very careful and tactful handling; utter demolition of a concerned relative's query is never a good thing. Shared understanding would be my aim here.

Declan Fox is a freelance physician

Dr Penny Bradbury

'Did I miss obvious ''red flags''? Of course, ''in retrospect'' is a fine diagnostic tool!'

It's not uncommon for people to approach me for information about family members, and the reply is always the same ­ without my patient's express consent, I cannot discuss any aspect of their care with relatives.

I suspect this isn't going to go down well with Mrs E, and the potential awkwardness of the situation will compound my unease at the way events have unfolded. Nonetheless, I have to explain about the rules of confidentiality, and how this prevents me from discussing any aspect of her mother's medical history with her.

Mrs E may well feel angry and upset about her mother's illness, and I need to acknowledge this. I will suggest that Mrs E inform me when her mother is discharged from hospital, when I will arrange to visit Mrs D at home.

If her mother is happy for Mrs E to be there, I will have the opportunity then to talk with them both about the issues surrounding the referral. In the meantime, I'll look through Mrs D's records again and discuss them with a colleague, to see if I did miss any obvious 'red flags' that would have warranted a two-week referral, although of course ''in retrospect'' is a fine diagnostic tool!

It is exasperating when hospital doctors make what appear to be ill-informed and inappropriate criticisms of general practice, but before getting too cross about this I need to consider whether the comments were actually well-founded.

Therefore I will write to the consultant in charge of Mrs D's hospital care and ask her to clarify the two-week referral guidelines with express reference to Mrs D's symptoms.

Finally, I will bring Mrs D's problem up at the next practice meeting as a significant event analysis.

This will also ensure that other members of the team are aware of the situation.

Penny Bradbury is a GP in Sheffield in a

PCTMS practice

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