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Keeping within the rules

Advice to practices about real-life dilemmas where it can be difficult to keep within GMC guidelines

GPs are highly knowledgeable and skilled individuals, and as such, are sometimes asked to use their skills and special statutory powers inappropriately, or may be asked clinical questions on an informal basis, outside the usual surgery setting.

Some GPs may be tempted to agree to a patient’s request through a desire to help, because they are pressurised, or simply because it is easier to agree than refuse.

In Good Medical Practice, the General Medical Council (GMC) gives guidance which limits how doctors can use these special attributes. GPs should follow the GMC’s guidance not only to protect themselves from criticism, but also because there are good reasons for each guideline. As responsible doctors, there will be times when, in order to fulfil our professional obligations, it is appropriate to decline a particular request.

Here are some examples

Painkillers for a friend

Your friend has a really bad toothache, and asks you to prescribe some strong painkillers. His doctor’s surgery is closed for the weekend, and it would take ages to get to see either the out-of-hours doctor or dentist. Should you agree?

Good Medical Practice says: ‘Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship.’

While it may seem practical and helpful to agree to prescribe, there are potential risks involved which could have negative consequences. Your friend may have a known adverse reaction to a medication, which you are not aware of.

GPs may also find that, after a few requests for medication, their friend has become addicted to prescription drugs. It may be more helpful in the long run to give your friend a lift to the out-of-hours centre and keep him company there.

Helping out at the race circuit

The local speedway team have asked you to help as a medical officer for their meeting tomorrow. Their usual doctor is visiting his mother in Australia. Without a doctor on site, you are told, the races will have to be cancelled. You are assured that there are never any injuries, and anyway there are trained paramedics always available. The money offered is good. Do you agree to help?

Good Medical Practice states: ‘In providing care you must recognise and work within the limits of your competence.’

You may be the unlucky one who has to deal with a major injury on the track, and the paramedics, though trained, may turn to you for leadership. You should only agree to assist if you have the training and skills that may be needed at the event, and should not otherwise bow to pressure or be tempted by the financial reward.

Holiday in Spain

Your patient’s daughter asks for her parents’ normal repeat medication, and a course of antibiotics ‘just in case’. It turns out that her parents have moved to Spain, but trust you and would rather you continue to look after them. The daughter thinks it would be reasonable to consult by email.

Good Medical Practice states: ‘Good clinical care must include … where necessary examining the patient. You must … prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs.’

Unless you can co-ordinate satisfactory clinical assessment and monitoring with clinicians close to your patients, you should not agree to prescribe.

A noble sacrifice?

As a salaried GP, you have noticed that your employer, a sole partner, is making many wrong diagnoses, possibly because he is going deaf. When you tell him of your concerns, he says that he has to continue working to pay his mortgage, and if you inform anyone else the practice will close and you will be jobless, and he would make sure you did not get another job in the area. Do you agree to stay quiet?

Good Medical Practice says that: ‘The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary.’

It might be painful for both you and your employer, but you have a duty to protect patient safety. It may be necessary to seek advice from a respected colleague or the PCT, but after a proper occupational health assessment, he may be able to continue working with some help, or with a limited workload.

Happy to help?

You have been called by the out-of-hours service, who are desperate for you to work tonight as another doctor has let them down. You have already worked three nights in a row, as well as your normal day job, and you are exhausted.

GMC provisional guidance says: ‘You should bear in mind, in relation to your own health and performance … the need to best protect patients’ safety and needs, balancing additional risks which may be introduced by fatigue, against the alternative … of patients receiving no care.’

Perhaps, at this time, it might be safer, in spite of their insistence, to decline to help the OOH team tonight, if you feel your tiredness might affect your judgment.

Doctors generally want to help – this is, after all, why many of us joined the profession. Sometimes, however, the best way to help is to say no, using professional guidance to protect others from harm and ourselves from criticism.

Dr Daniel Kremer, is a medicolegal adviser at the Medical Protection Society

When it might be best to say ‘no’

• When asked to give medical advice in social situations
• When asked to sign documents – reports, certificates and references – when not satisfied that the contents are true
• When offered a valuable gift
• When asked for information about a patient by a close relative, when no consent has been given

Dr Daniel Kremer, is a medicolegal adviser at the Medical Protection Society