I receive a call from a patient who says she is experiencing symptoms she believes are caused by a medication I prescribed last week. I advise her to book an appointment as soon as possible. She then says she is calling from abroad and does not know where she can access a reputable doctor. What advice can I give over the phone?
GP trainer view: Refer to local emergency services if concerned
Before you offer any advice, review the patient’s record and remind yourself of her history, your most recent consultation with her, what drug you started, the indication for it and what counselling you provided. If the patient had told you she was due to travel, remind her what you told her to do in the event of side-effects.
Establish what symptoms the patient is experiencing. Any evidence of life-threatening illness, for example symptoms that suggest emerging anaphylaxis, will require you to signpost the patient to the local emergency department or ask her to call local emergency services.
If after your triage you feel the symptoms are probably secondary to the medication you prescribed, ask the patient to stop the medication in a manner you feel is safe and ensure a prompt review by yourself or a colleague when she returns.
If she still has the original symptoms that the medication was started for and you feel an alternative is urgently necessary, encourage her to attend the local hospital, explaining the rationale. Ensure your discussion is fully documented.
If the patient has travel insurance, or a European Health Insurance Card if she is in Europe, it may be worth her calling the insurer or telephone number on the card to find out which local healthcare services they recommend.
You may wish to run the case by your medical indemnity organisation, as some providers do not cover clinicians being consulted by patients abroad, even if it is their own patient and they are only away for a short time. Ensure you are able to call the patient back later if you need to do so.
Dr Pipin Singh is a GP trainer in Wallsend, Tyne and Wear
LMC view: Check your indemnity policy first
Be aware you may not be insured to give advice, as medical defence organisations usually will not indemnify you for a claim originating outside the UK.
If you know you are not covered, you can advise the patient to see you on her return and offer to book this appointment over the phone. If you feel she needs to be reviewed or to have alternative medication before returning to the UK, tell her to seek medical help there and that you are unable to offer further advice. If you feel the symptoms do not warrant a review, it is up to you whether you feel comfortable to give simple advice over the phone.
If unsure about your insurance cover, contact your defence organisation before taking any action. Each takes a different approach. The MDDUS states there are increased risks associated with treating patients in other countries and advises members not to offer any medical advice to a patient who is overseas, other than to see a local medical practitioner.1 However, the MDU allows a degree of discretion; if a patient has an enquiry about a longstanding condition, the MDU says it ‘would have no difficulty’ with the GP providing advice or information.2
If the patient is unsure where to seek appropriate advice, suggest she contacts her hotel or travel representative, talks to her travel insurer and looks at the information provided in her holiday accommodation. Do not offer to do this on her behalf.
Dr Hannah Casey is vice-chair of North Essex LMC
Medicolegal view: Do not agree to send medication
You should take a detailed history of the symptoms and any other relevant history, such as the patient’s medication, her current location and the date she intends to return to the UK. Consider that she may be wrongly attributing the symptoms to the medication you prescribed. Also, be aware of the limitations of assessing her over the phone. You should have an extremely low threshold for suggesting she seeks advice from local medical services – if not a family doctor, maybe the local hospital.
You should not agree to export medication to the patient as you might fall foul of regulatory, export, legal and insurance or indemnity requirements in the other country.
It is important that you follow GMC guidance for assessing the patient’s condition.3 Make a detailed contemporaneous note of any information and advice given, in case you need to justify your actions.
You might direct the patient to reputable resources for management of health conditions relevant to the country of travel, provide advice on managing flare-ups of chronic illnesses while abroad and remind her of the importance of obtaining adequate travel insurance before going abroad.
If you have any doubt about your indemnity, contact your defence organisation.
Dr Richard Stacey is head of policy and technical at Medical Protection
1 MDDUS. Advice to patients travelling overseas. August 2014.
2 Wickware C. GPs advised not to give phone consultations to patients travelling abroad. PulseToday; April 2018.