Practice Dilemma - Aciclovir for chickenpox

The Dilemma - A young woman who runs her own business attends the surgery to discuss her five-year-old child, who has just developed chickenpox.

Antivirals are not always indicated for cases of chickenpox (Photograph: Guillaume / Science Photo Library)
Antivirals are not always indicated for cases of chickenpox (Photograph: Guillaume / Science Photo Library)

She says the diagnosis is certain because a friend's child has just had it. She wants a prescription for aciclovir, because she read on the internet that if used within 24 hours, it shortens the illness, which, she adds, would enable her to make an earlier return to work.

The local pharmacy refused to supply her and sent her to see you. You look up an authoritative source during your consultation with her, and show her that aciclovir is only recommended for complications. You decline a prescription and give her general advice, but she storms out whilst threatening a complaint. Should you have relented, and what should you do next?

A GP's response - Dr Zara Aziz is a GP in Bristol

There are several issues here including miscommunication and breakdown in the doctor-patient relationship. It is important to have acknowledged the mother's concerns and expectations. She is keen for her child to recover early, but also wishes to have a quick return to work. She is self-employed and is likely to have lost earnings from any time off. This has formed the basis of her visit to the GP surgery.

It is useful to discuss the incident with the practice manager and other senior GPs at the practice to decide on the best course of action. Whether or not a complaint is generated it is important to resolve the dispute quickly.

The mother should be invited to come in and discuss all her concerns with the GP and practice manager. She should be given an opportunity to explain her reasoning behind the request for aciclovir.

An apology should be made as the intention was not to cause her any offence or upset. The doctor's intention was to act in the best interests of the child. They can discuss the fact that although the internet contains a wealth of information this is not always reliable or peer-reviewed.

In milder cases of chickenpox in immunocompetent children it is not always necessary to prescribe antivirals.

The need for medication always has to be balanced against any potential side-effects to the child.

The issue may be resolved through amicable discussion but medico-legal advice may be sought if this is not the case.

The event can be recorded as a 'significant event' in the GP's personal log.

A medico-legal view - Dr Richard Dempster is a senior medico-legal adviser at the Medical Protection Society

There is certainly no doubt that whatever the rights and wrongs of this consultation, it has had a unsatisfactory ending.

The GP may well have been correct in their analysis of the indications for prescribing aciclovir. However by focusing on this, the GP has come into direct confrontation with a mother who not only believes her child to have chickenpox, but is worrying about the effect this will have on her own work.

A sympathetic approach to the situation, plus an offer to arrange an assessment of the child to confirm the diagnosis, is much more likely to both appease the mother and satisfy the GP's own scruples on whether or not to prescribe aciclovir as requested.

Chickenpox (varicella zoster) can be an unpleasant illness, although normally mild in an otherwise healthy child in this age group.

You could explain the general course of the illness to the mother and advise her on what particular signs she should look out for, in case a further assessment of the situation from a healthcare professional becomes necessary.

Ultimately, the information you have looked at for prescribing aciclovir is only a recommendation - it is not prescriptive. Your own assessment of the whole situation in this case could possibly justify a compromise in your approach, and certainly avoid a potentially serious and unpleasant complaint. Whatever your decision, seeing the child yourself would certainly provide you with a sound basis for justifying your decision in the future should this be required.

A patient's opinion - Gillian Whitehead is an expert patient

I believe the GP was right to refuse the mother a prescription for aciclovir. The mother had placed the GP in a difficult position by diagnosing her child's illness herself and demanding a prescription based on the knowledge she had found on the internet.

She is self-employed and it is understandable that she wishes to get back to work as soon as possible, but the child's health should be a priority for the GP. The mother should be aware that every drug has side-effects and giving medication to a child (who may not need it) could have consequences that may lead to the child being ill for a longer period of time, as well as causing more distress.

The GP looked up the authoritative source to back up the advice that had been given. I feel the GP did what they could to pacify the mother.

In terms of what to do next, the GP should write a clear and concise report of the consultation and place it in both the child's and the mother's notes. The GP should then inform the practice manager that there may be a complaint from the mother and suggest that the practice manager should inform the mother of the complaints procedure.

The GP should make colleagues aware of the situation and the consultation, as the mother may choose to consult one of them for the same reason.

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