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Uncertain times demand a clear financial plan

Three GPs share their approach to a practice dilemma

Case history:

Mrs Willis brings her seven-year-old, Martin, to your surgery with acute tonsillitis. This is the fourth time he has presented with this in the last year. You offer to refer Martin to the ENT department, which Mrs Willis accepts. She tells you they have insurance so you refer Martin to a private hospital. The insurance form arrives the next day and after reviewing the records you fill it in.

A few days later you are surprised to find Mr and Mrs Willis have sent the form back to you with a letter asking you to reconsider the way you have filled it in. They are referring to an episode you have detailed that happened over two years ago, before they had insurance.

The final paragraph states: 'If the form is not amended Martin will lose his place on the theatre list next week, and you will be responsible for this.'

Dr Des Spence

'Patients always feel justified and getting defensive only makes them pursue you harder'

Emotional blackmail is the standard fare of general practice. In this situation it would be natural to get defensive and dig my heels in. But general practice is a long-term relationship and being difficult with patients often comes back to haunt you. Never ever lose your temper and, as my daughter, says 'be cool'.

This scenario is common and I have three options. First, I could take the black and white 'it says what is says' approach. But as with most situations in life, this is not very helpful. Second is the 'be economical with the truth' option. But unless I want regular contact with my defence union I would avoid this approach.

We may hate Tony Blair after the new GP 'con-trap', but third ways are often best. Clinical records are open to interpretation and what we write on reports is, to an extent, open to our professional discretion. For example in this situation a sore throat might be a 'pharyngitis' or a 'tonsillitis' ­ get it?

However fed up I might feel about this family I would get this complaint sorted out quickly. I deal personally with patients even for minor complaints, and I'd start by phoning Mr and Mrs Willis on the day I received the complaint.

I also always say sorry! Patients always feel justified and getting defensive only makes them pursue you harder. This is not an admission of responsibility, but merely a recognition of their feelings.

In this particular situation I'd suggest we meet the next day to jointly review the case records. If there is some leeway for interpreting the records I might consider amending the report. But, if not, most people will respect the fact you can't lie.

Mr and Mrs Willis may still be unhappy, and as a compromise I could suggest an NHS referral. In this case I would also suggest that a tonsillectomy may not be indicated and a second NHS opinion where private surgical fees weren't involved would be best.

Des Spence is a GP in Glasgow and a tutor in general practice at the University of Glasgow ­ he completed the VTS in 1995

Dr Lucy Free

'I would telephone the parents and attempt to explain that I prefer not to perjure myself'

The answer to this problem is in the parents' threat: 'You will be responsible.' I am entrusted by the insurance company to complete the claim form to the best of my knowledge. In fact, it almost certainly says that somewhere near where you sign it. I would therefore have no problem telling the truth, the whole truth and nothing but the truth without fear or favour. Imagine the embarrassment and implications should my 'reconsideration' become public.

These expectation/reality mismatches are unfortunate and are usually based on ignorance. These poor parents have probably endured sleepless nights, wasted school fees and considerable anxiety about Martin's future. The benefit of unexpected corporate private insurance must have seemed heaven sent. They probably didn't read the small print excluding pre-existing conditions, and have been taken aback at the prospect of a four-figure bill rather than a restorative week on the Costa del Sol.

To most people in business there are risks to be taken, boundaries to be probed and deals to be made. But medicine isn't quite like that; it is much more black and white than one might imagine, with just an artistic veneer of compassion and understanding to affect the interpretation of facts. This situation is not negotiable. Either a passport photo is a true likeness, or it isn't. Either the child has been seen previously, or he hasn't ­ there is no halfway.

These are regrettable circumstances, but it is important to be straightforward. I would telephone the parents and attempt to explain that I prefer not to perjure myself, and to send them a copy of the notes if necessary.

Despite their disappointment it should be possible to reassure them that there are no associated long-term problems, that the condition is not life threatening, and to encourage them to persevere with schooling and paracetamol. But it is most important to be responsible.

Lucy Free qualified more than 20 years ago and is a GP in Hurstpierpoint, West Sussex

Dr Prashini Naidoo

'I would aim to act professionally

in the face of emotional outbursts'

In the final paragraph of their letter Mr and Mrs Willis are attempting to shift responsibility for matters outside my control on to me. It makes me feel a bit threatened and overwhelmed, perhaps because these are emotions that they are feeling and then transferring on to me. Are Mr and Mrs Willis rude and pushy, or simply afraid? My final opinion would be based on our previous contact and our 'mutual investment fund.'

At the end of a busy day my tolerance may be at an ebb, and if they are indeed being rude is it really worth being upset? Would asking them to behave more appropriately (by writing a letter or inviting them to an appointment) achieve the desired effect? I wouldn't want to waste my time trying to change their bad behaviour.

The most expedient course of action in the face of rudeness would be to behave professionally. I would firmly and clearly spell out my professional responsibilities to the family and point out that I can't manipulate information to serve the patient's end. My job in this situation would be to present the past medical information to the insurers ­ it is someone else's responsibility to act on it.

By completing the form quickly and honestly I have acted responsibly and ethically, which it what my patients can reasonably expect of me. The non-NHS fee covers the cost of this service; it doesn't pay for the contents of the insurance form.

If, on reflection, I feel that perhaps I worded my remarks unthinkingly and that they could be interpreted in a bad light, I would apologise and redo the form.

Ultimately, what I do would be determined on my past knowledge of Mr and Mrs Willis, and I would aim to act professionally in the face of emotional outbursts.

Prashini Naidoo completed the VTS in August 2002 ­ she is a salaried GP in south Oxfordshire. She recently completed a diploma in occupational medicine and is now studying towards a Masters degree in primary care development

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