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Unforgiving patient is a bully

Three GPs discuss a difficult practice problem

Case history

Matthew is 41 and had a Dukes C adenocarcinoma of the bowel resected six years ago. He had had symptoms of irritable bowel syndrome and episodes of rectal bleeding when straining since he was 26. Once he presented with another episode of bleeding, which was slightly darker than usual. Physical examination was normal. There was no family history of bowel cancer and he had not lost weight. You referred him because of the altered blood in his stool. After a five-month delay he was seen at the colorectal clinic and was sent for a colonoscopy, which found the tumour. After laparotomy when the histology was known, the registrar had commented that the prognosis would have been better if Matthew had been seen earlier. Matthew had adjuvant chemotherapy and has since been well with no sign of relapse. He has demanded visits for minor problems three times in the last year. You have suggested that he might want to find another GP. He always reminds you of the delay in diagnosis and implies that you are 'lucky' that no formal complaint was made. Today he attends with dyspepsia and demands an urgent referral.

Dr Linda Miller

'He may be terrified and assuming that his cancer

has returned'

Matthew is probably terrified by his new symptoms and assumes they mean the cancer has returned. He has lost faith in the medical system.

I would apologise to him for the delay, (regardless of whose fault it was) and emphasise the positive, reminding him of how well he has been since his treatment. I would acknowledge that he is likely to be more anxious about his health since having cancer. It may be helpful to explain to him the outcomes of a significant event analysis conducted as a result of a similar experience: The GP adds the date of referral and the name of the specialist. If phoning the appointments office is not successful, the slip advises the patient to return to the practice to chase up the referral.

I would suggest the practice manager would like him to make an appointment to discuss the new referral measures.

At this time she could reiterate the practice policy and patient responsibilities regarding emergency appointments and visits. Talking about practice policies and delegating to the practice manager will prevent his complaints from becoming a personal issue.

After taking a thorough history and an examination I would discuss the differential diagnoses of dyspepsia with Matthew.

I would emphasise that he has not had sinister symptoms such as melaena or weight loss. It might be helpful to go through the guidelines on referral for dyspepsia with him.

If he still wanted to be referred I would send a referral letter explaining his past history and current fears.

I would also emphasise that in the meantime the specialist would expect him to have tried simple treatment for dyspepsia.

Dr Rupal Shah

'Because of guilt over the diagnostic delay I may have let him bully me and the staff'

It seems to me our doctor-patient relationship has deteriorated to the point where I have been allowing Matthew to bully not only me, but also other staff in the practice ­ probably because I have been feeling guilty about the delay in his diagnosis and perhaps worried that he will make a complaint if not placated.

This has obviously led me to feel a certain amount of resentment towards him; after all, I have already suggested that he should try to find another GP. The fact that he has declined to do so may indicate that there is still some hope left ­ perhaps his behaviour is a means of venting his anger and fear about his diagnosis.

Matthew is a young man who may have a family and it must be very difficult for him to come to terms with the uncertainty of his prognosis. I would deal with the immediate problem by agreeing to refer him, but would also confront him about the way he has been behaving, by acknowledging that I am aware he is angry with me. I would ask him to write down the ways he feels he has been let down and to come in to see me to talk about these issues.

I would discuss Matthew at our practice meeting and ask my colleagues for their opinions about whether I should have acted differently ­ it might even be worth carrying out a significant event analysis. Maybe we need to review our practice guidelines about rectal bleeding.

After all this, the conclusion may well be that Matthew has just been very unlucky and that there is nothing else I could have done, but it may be important for me to hear this from someone else.

It is obviously going to take a lot of effort to rebuild our relationship, but should Matthew remain abusive it may be in everyone's best interests if he registers with another practice.

I hope that after his next appointment his behaviour will be better. He will need a lot of input from whichever GP he stays with, as well as possibly from ancillary services such as counselling.

Dr Jason Twinn

'I would broker a compromise once I had excluded any sinister symptoms'

There are two issues that need addressing here. The first is of course his dyspepsia, and it is understandable that he is going to be anxious about what he may perceive as another morbid symptom.

While I am loath to use RCGP clichés I think it might be productive to explore his ideas, concerns and expectations surrounding his dyspepsia. Hopefully this would enable me to address some of the issues directly.

I would perhaps try to broker a compromise of PPI, H. pylori testing and open-access gastroscopy once I had excluded anything sinister about his

symptoms.

But until the practice has successfully tackled the second issue (his attitude) I might be micturating into a hurricane trying to negotiate the first. As a practice we need to discuss what strategy we are going to take with him.

Personally I would favour tackling his behaviour by inviting him to a discussion with a GP and practice manager, rather than pandering to his every whim in the hope that he doesn't complain.

It also must be remembered that the NHS complaints procedure will hang a GP before the PCT will tell the patient where to stick their complaint even when the latter is purely malicious and unfounded.

I would not be in favour of removing him from the list ­ despite the fact that he would probably benefit from a new untainted doctor-patient relationship ­ as this is probably inflammatory, if not explosive.

But attempts do need to be made to contain his behaviour lest it escalates out of control.

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