CASE STUDY DIFFICULT PATIENT
Manager Practice
tolerance Day one
Mr P is 53-year-old arts administrator. He has been a patient at the surgery for five years and is a frequent attender with a reputa- tion for being demanding and sometimes rude and abusive to staff when he does not get his way. He phones the surgery first thing in the morning and demands an emergency appointment.
Later that day
Mr P is seen by a young GP locum – Dr L – and enters the consulting room with a plastic folder bulging with printouts from the internet. Even before the doctor can ask what the problem is he says: “I need for you to arrange some blood tests to check my vitamin levels – in particular A, D, E and K.” He informs the GP that he has inflammatory bowel disease (IBD) which affects the absorption of fat soluble vitamins. Dr L checks the records and notes that Mr P has been investigated previously and diagnosed with irritable bowel syndrome. She explains that the two conditions are different – IBD being much more serious. Mr P replies “I’m not stupid” and stands up from his chair, thrusting a print-out into Dr L’s face. “Look at the symptoms. I’ve been misdiagnosed. The blood tests will confirm that!” Dr L calmly asks the patient to sit down. She explains that such tests are not routine and first she must take a history of the complaint and then do an examination. Only then can she order relevant tests. Mr P grows angry and accuses Dr L of being ignorant along with the rest of the staff – especially the female ones. He stands up and shakes a finger in her face ranting about how it’s just the NHS trying to save money. He then kicks over his chair and storms out the room.
Day three
The practice manager – Ms K – writes to Mr P to say Dr L has informed her of his ag- gressive conduct during the consultation. In the letter Ms K also refers to a number of previous incidents in which Mr P had been verbally abusive toward staff, including an incident when she had tried to arrange a referral for him to a local homeopathic clinic. Mr P had shouted and accused her of incompetence over the phone before hanging up. On that occasion she had written to Mr P stating: “Please note that this practice operates a zero tolerance approach. No form of aggression against staff, verbal or physical in nature, will be tolerated and this letter is to inform you that any repeat of such behaviour may result in you being removed from the practice’s list of registered patients.” Given the further incident of abusive behaviour Ms K now informs Mr P that he will be removed from the practice list and that the local CCG has been informed of the reasons behind his removal. The removal will take effect in approximately 10 days and she suggests Mr P register with another practice.
Day five
Mr P writes a letter in reply to the practice manager refuting that he acted abusively or with aggression. The letter states he is aware that the doctors have been keen to be “rid of him” as he does not “conform to their ideal of the submissive, unquestioning patient”. Mr P then states that Ms K’s criteria for “abusive” seems subjective at best and that he would describe his behaviour as “forthright”. He concludes the letter by saying he will be taking the matter up with the Ombudsman.
T 14
HE practice manager contacts MDDUS for advice on the complaint. Ms K drafts a reply and forwards it to an MDDUS
medical adviser to review. Among other advice it is suggested that all staff members abused by Mr P provide an account of the ex- perience including administrative and clinical details. Dr L should also provide a full account of the consultation on Day one. Ms K is sent a copy of GMC explanatory
guidance on Ending your professional rela- tionship with a patient. She is also provided with a link to guidance by the Royal College
of General Practitioners on the removal of patients from the practice list. A week later Ms K posts a reply to Mr P’s
letter stating that the practice has consid- ered his comments. She restates the reasons behind the decision for removal, adding that there has been a breakdown in the doctor- patient relationship and it is clear that Mr P no longer has confidence in the GPs in the prac- tice. She again advises the patient to register with another practice so that a transfer of records can be quickly facilitated.
KEY POINTS
• Ensure practice leaflets include policies on removing patients and “zero tolerance” to violence/abuse.
• A patient being removed from the practice list should have been given a written warning within the last 12 months.
• Consult GMC, RCGP or BMA guidance on patient removal.
SUMMER 2014 ISSUE 10
ZERO
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