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Should you rubber-stamp a patient request for referral?

Mrs Bevan only consults seeking a referral to her specialist of choice, usually courtesy of her private health insurance. Your trainer always complies, but he is away, and today she wants you to refer her about her cough. She is reluctant to discuss it any further. Dr Melanie Wynne-Jones offers advice.

How might a request like this make you feel?

Coughs are bread-and-butter problems, and GPs have both the skills and expertise to diagnose and treat almost all of them. GPs' ability to recognise which patients require further investigation is also enshrined in their role as gatekeepers to the NHS.

You may feel angered or belittled by Mrs Bevan's refusal to acknowledge your competence; you are not just a rubber-stamp after all. You may also be angry with your trainer if you feel his previous actions have put you in this situation, or tempted simply to shrug your shoulders and agree.

Feeling angry in a consultation is always unsafe; it disturbs concentration, and you may make an unprofessional remark or a serious clinical mistake. It is important to recognise and deal with your feelings before continuing.

But it can be very illuminating to examine negative feelings that arise during consultations ­ they can provide valuable insights into patients' behaviour, our own belief systems and our professional relationships. Even if you are running late, a few moments' reflection before the next patient may be time well spent. Debriefing difficult consultations with colleagues can also help, both at the time, and in reducing long-term work-related stress.

How should you respond to her request?

Mrs Bevan may well be right; her cough may indeed warrant referral to a chest physician. It will certainly speed up your surgery if you just agree, and write a referral letter containing minimal detail (although this is unlikely to impress the consultant!).

Explaining to Mrs Bevan that taking a history and examining her now could actually solve her problem more quickly and conveniently, or help you to ensure that she sees the most appropriate specialist for her particular complaint, may cut some ice.

You might also wish to add that you have a duty to use both NHS and private resources responsibly, and that you will be unable to countersign her insurance claim form unless you have enough information to satisfy you that the referral is necessary.

She will either resent your interference, or be impressed with your concern and thoroughness, and perhaps revise her opinion of GPs!

Why should Mrs Bevan behave like this?

There are many possible reasons, some of which are more understandable than others. She may have morbid fears about her health which can only be allayed by reassurance from specialists whom she regards as having almost-magical powers. She may have been brought up in a family where recourse to specialists was the norm, or she may know someone whose serious diagnosis was apparently missed by the GP. Her husband or other relatives may be pressurising her to act in this way: doctors and other health care professionals often do this.

Some patients feel specialist care is an automatic right, because they have paid their taxes or private health insurance fees. Some believe in 'going straight to the top'; a small number simply want to boast to others that they have done so.

An alternative explanation is that Mrs Bevan is extremely well informed about her own health, self-manages appropriately, and only bothers her GP when specialist treatment is indicated.

So should you challenge her yourself?

You may get a worthwhile result, but alternatively you may uncover more than you bargained for, or cause unforeseen distress. She may accuse you of youth and inexperience, or even make a complaint.

As she is your trainer's patient, it is probably wiser to discuss this with him first, or leave him to decide on further management. This might also apply if you were a partner, although you might then feel competent and confident enough to take a calculated risk.

Key points

 · Feeling angry with a patient can be both enlightening and dangerous

 · Patients must be made aware that GPs must use resources appropriately and cannot simply rubber stamp their demands

 · Exploring the reasons behind patients' requests can be revealing, and suggest a solution

 · If a patient makes demands that seem unreasonable or make you feel uneasy, it can help to discuss the situation with a colleague

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