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Woman with abdominal pain demands to see male partner

case history

You, a male GP partner, are in the middle of an overbooked surgery when the receptionist tells you 25-year-old Miss Smith is asking to see a doctor urgently about a 'confidential' problem. When you suggest Miss Smith should see your female partner, who is the on-call doctor for today, the receptionist tells you Miss Smith has refused point-blank to see her, or indeed your female registrar, and insists on seeing you.

Looking at her records confirms you have had no particular dealings with her before apart from a Pill check last year. You note, however, that two weeks ago Miss Smith consulted your female partner, complaining of lower abdominal pain.

Three GPs share their approach to a practice problem

Dr Alex Williams

'Try to tease out the reason she won't see female GP'

A variety of thoughts are running through my head – why me, why now? However, the first priority must be patient safety. A

25-year-old woman with lower abdominal pain for two weeks could suggest a variety of pathological processes so she clearly needs assessment.

I may ask the nurse to make some basic observations for me (playing for time) and then see her between patients and obtain a full history and appropriate examination.

I would want to know about last menstrual period (ectopic?), and whether she has a temperature, and right-sided pain (appendix?), or a discharge and dyspareunia (pelvic inflammatory disease).

Other more sinister pathology is unlikely but should be in the differential, for example ovarian cyst or gynaecological/lower gastrointestinal malignancy. History, examination and appropriate cerebral activity should lead to appropriate treatment and or referral.

Having dealt with the clinical problem, I would try to tease from her the reason she didn't want to see the female partner or the registrar. Is she just a female misogynist or has something inappropriate happened with your colleague?

Any allegations of misconduct would have to be investigated, perhaps by discussing them in confidence with the practice manager and other partners, in the first instance and if a pattern of behaviour emerges this will have to be addressed with the partner, perhaps initially on a one-to-one basis or with the help of the practice manager (to corroborate what was said).

There may be an innocent explanation – perhaps a clash of personalities, some misunderstanding from the past or they have a social connection, which is not that uncommon and it goes with the territory.

Dr Rodger Charlton

'Just fitting her in might add to my stress load too'

When push comes to shove, patients should be able to choose the doctor they see wherever practical. However, I could not see her there and then but I would offer to see her at the end of surgery and, to make life easier for both of us, I would ask the receptionist to arrange a time.

But if she prefers, she would be welcome to sit and wait, but this is not ideal. Regarding the urgency of her request, I would also suggest the receptionist confirms she is not actively in pain and that there is no other reason she should be seen urgently. To 'fit her in between patients' seems unfair on others who are waiting and would add to my stress load too. I would probably be running behind time anyway as I am overbooked.

The relevance of her abdominal pain is difficult to know until I see and assess her and she may be coming to consult about something completely different. Or it may be that she was dissatisfied with her previous consultation with my GP partner and perhaps there is a misunderstanding that needs to be resolved as soon as possible.

Issues such as pelvic inflammatory disease may be a possibility but one shouldn't jump to conclusions, and I can recall similar cases where the diagnosis of pregnancy has been overlooked. Similarly, I should be alert to other causes of abdominal pain such as appendicitis or an ectopic pregnancy. Or it may be that she wishes to see a male doctor.

This woman has made a request to see me and it seems appropriate to agree to this. It would be unreasonable to ask the receptionist to ascertain why this must be me rather than the other doctors that have been offered.

Dr Des Spence

'Enlist the help of your practice smoothie'

Reception areas are small, full of gossipy

local people – and they're merely the staff. Doctors storming out into waiting areas and having running verbal battles with a patient is a drama you don't need. If something is kicking off in the waiting area, get it sorted quietly and quickly.

The fact that she won't see a female is odd and might set some minor alarm bells off. Two options: first, organise a time to see her at the end of this surgery; second, see her right now and find out what the problem is.

Running late is preferable to four hours responding to a complaint letter. The stock phrase 'the doctor has been called to an emergency' along with an apology should quell the mob in the waiting area.

See Miss Smith on your own and listen to her story. She may be upset, angry, anxious or more likely all three. Try to see it from the patient's perspective, however distorted and self-absorbed this might seem!

Actively listening almost always defuses complaints. Apologising is not an admission of guilt. Remember, attitude is paramount and being defensive or evasive fans the flames of any complaints – most have a legitimate point. Ideally every practice should have a 'patient whisperer' to becalm complaints – so enlisted the help of your practice smoothie.

With regard to your female partner, you have a duty to protect her but cannot answer on her behalf. This complaint might be nothing more than a simple misunderstanding or a standard clash of personalities.

Explanation and perhaps a phone call

later from your female partner should sort this. But if there is evidence of a major clinical error or even the suggestion of possible impropriety, then you have to deal with this head on. Never use denial or avoidance, as believe me, the truth will out. Do not do what is easy, do what is right.

What does this incident teach us?

Learning checklist

Emergencies in surgery

• Having an on-call doctor with some spare capacity is the most common system. Patients are directed to this GP rather than a GP of their choice.

• Benefits include freedom from this stress on other days of the week and a clear line of responsibility.

• Disadvantages include loss of continuity for patients, loss of choice and sometimes excessive workload falling on one GP.

• Where a GP does need to go out of surgery to visit a patient, having a policy about offering appointments with the remaining doctors to reduce the backlog is useful.

• Clear guidance needs to be given to receptionists about the sort of emergency that needs to be put through immediately to the GP. Often these are visit requests which require an ambulance rather than a visit.

• Less intrusive ways of telling GPs of urgent problems can be developed, including e-mail and message books.

• Guidelines fall down when patients make themselves an emergency by refusing to fit into the system, as described in this example. These incidents require careful handling as immediate agreement to the patient's demands can undermine the receptionist, who was following your clearly laid-out policy. However, it's your surgery and stand-up arguments with patients in the reception area can damage the practice reputation and place confidentiality at risk.

Why do patients choose a particular doctor?

• Asking the question 'why is this patient seeing me, why now, why not their usual doctor?' allows you to progress beyond feelings of being burdened and mistrust to active curiosity and challenge.

• Their choice may be influenced by their previous experiences of you, a perception of your expertise in a particular field or a feeling that you are closer to their wavelength.

• You may also be seen as a second opinion, especially if you are a more senior doctor within the practice.

Potentially compromising patient

• A female patient who has refused to see two female doctors would raise alarm bells for most male GPs. Some measures could be taken to reduce

the risk of a malicious accusation. Maintain a very polite professional manner during the consultation, avoiding the use of humour, which

can easily be misinterpreted.

• Actively seek informed consent before any examination and insist on the presence of a chaperone.

• Taking meticulous notes, including the name of the chaperone, is important and I would avoid making home visits in these circumstances.

Angry, upset patients

• Listen to the patient's narrative.

• Interrupt only to encourage them to explore this in more detail.

• Avoid giving your own interpretation

of what might have gone on.

• Empathise.

• Try to help with the presented medical problem but stall any response to their complaint about how they have been treated until you have all the facts.

• Offer investigation through the practice complaints procedure.

Richard Stokell is a GP in Birkenhead

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