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Why is it so hard to deny a patient that which they really want?

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‘If you don’t prescribe it to me doctor, I’ll only buy it online,’ said the 58-year-old smoker this week, as she reached the pinnacle of her argument as to why I should continue to prescribe her hormone replacement therapy (HRT).

We’d long before talked through her age, the smoking, the fact she’d been on it the best part of 10 years, as well as the risk of venous thromboembolism and  cancers – to which she responded: ‘It reduces the risk of colorectal cancer doctor, don’t you forget that.’ Thank God I’m still on 15-minute appointments.

For each well-researched and proven risk I explained to her, she had a counter-argument already lined up. It soon became obvious she had had these discussions every six months with GPs for the past five years.

She had, it appeared, what the RCGP would describe as ‘unusual health beliefs’.  Apparently, stopping HRT makes you age 10 years almost instantly. It’s stress and poor quality food that cause cancer, not HRT. Not to mention that doctors don’t really know about these things, not really.

At what point do we simply say no, and tell her that, if she wants it, she needs to buy it online?

Well, I’m embarrassed to say after 15 minutes of circular arguments I signed the prescription, reasoning to myself she was over 18, of sound mind, and knows the risks – therefore it’s ultimately her decision. As she left, with a wily smile, my heart sunk low. 

Why is it so hard to deny a patient that which they really want? It appears the decision to stop prescribing HRT to this patient has been postponed to a later date – I just hope she books in with a partner next time.

Julie Fry is a GPST3 in Cheltenham

Readers' comments (4)

  • This has always been a nightmare and my deepest sympathies. I get this a lot with historic prescribing and I am always told the other Dr didn't have a problem prescribing them. Almost making me feel that to suggest weaning is in some way a rude and taboo topic that I shouldn't really be discussing. Unfortunately, we must persevere and inform of risks and as you say, allow grown ups to make sensible informed choices.

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  • Hazel Drury

    Yes. Allow her to make her own choice like you said.. so go and buy it from DodgyDrugs.com - you'd be the first to be held responsible for giving her HRT on presription by the family if she has a CVA.

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  • Ultimately it is your decision, having weighed up the pro's and cons, if you think a prescription is appropriate and safe. It is tempting to postpone the decision but this bases the doctor/patient relationship on a bit of a falsehood on both parts. Offer the patient the advice and prescriptions you think are appropriate and be open and honest about it.... this allows the patient to choose if they wish to stay with you.

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  • The patients views should also be respected. Ultimately it is neither the decision of the patient nor the doctor alone.

    Surely the doctor should make clear the alternative treatments available and highlight the risk and reward with each.

    The patient can then make an informed choice based on the information presented to them.

    Whilst you may disagree with the choice the patient made it was surely the patients choice?

    The clinical notes will backup the guidance offered to the patient and the patients choice of treatments.

    I would be concerned whether this patient is already taking unprescribed medicines purchased online and the dangers of continuing to prescribe in this situation.

    This presents quite a dilemma

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