During a morning surgery, a patient in his forties came to the surgery to see me. He was very upset because he could not obtain insurance to go on a residential dry-slope skiing course after he had informed the insurance company that he was taking warfarin following previous hospitalisation for knee surgery.
He claimed he had already booked and paid for the course and he insisted that I write a letter to the insurance company confirming his fitness to ski on a dry ski slope.
However, during the course of the consultation, he let it slip that instead of dry-slope skiing in the UK, he was going on a week-long skiing trip to the French Alps.
I told him I would see what I could do and asked him to come back to see me the following week. What should I do?
A GP's view
Dr Raj Thakkar is a GP in Wooburn Green, Buckinghamshire
GPs are given responsibility to judge a patient's fitness to travel and care must be taken to try and not predict the future but rather make statements about their current state of health.
When reporting for an insurance company it is important you are honest and you do not collude with the patient for the gain of the patient, financial or otherwise.
Patients may lie, be very persuasive and even threatening, but you must not deviate from the truth. It is best openly to explain to the patient that you are unable to lie in the report under any circumstances.
It should be reiterated that the insurance company is refusing cover because the risks to the patient are high, and I would explain to him what these risks are.
If the patient does not like your report, he is within his rights to ask you not to send it but you should not amend it with falsehoods.
I would certainly mention in the letter to the insurance company that the patient requires warfarin for their medical condition and this increases their risk of bleeding, particularly in the event of any accident such as doing any form of skiing.
Fortunately, you are not obliged to write a report there and then, which gives you time to receive professional advice. Your main aim in this case is to act responsibly. Discuss the case with your medical indemnity body and share the case with your colleagues in a significant event analysis.
A patient's view
Ailsa Donnelly, Patient Partnership Group
I do not see how a patient can ‘insist' that a doctor writes a letter confirming fitness against their clinical judgment, and I sincerely hope no doctor would do so.
If the patient is reluctant to accept this, then you must stand firm and attempt to calm the patient by explaining the reasons for you opinion and stressing that it is in the patient's best interests, together with the moral, ethical, professional and possibly legal grounds for refusing to supply a letter where you do not outline the risks that a skiing accident could mean for a patient taking warfarin.
You should allow the patient to talk out their feelings and try to empathise - it is a shock for anybody to discover that something they enjoyed doing is now out of bounds.
With time he may accept that skiing is now something that he should not be doing. If you feel that dry skiing might be permissible but Alpine snow skiing inadvisable, then the patient must be warned of possible risks and consequences.
The patient should also be advised that the insurance letter will specify dry skiing only and cannot be used to obtain insurance for a skiing holiday abroad.
The patient should also be warned that if the letter is used to give a false impression to gain insurance cover then any medical insurance claim is likely to be seen as invalid.
A medico-legal view
Dr Iain Barclay, head of medical services (Leeds), Medical Protection Society
This is quite an unusual situation in that I was not aware that insurance is required to dry ski. However, you should not be cajoled into writing a letter at the patient's behest finding fitness to ski on dry ski slopes, unless to give such an opinion is within your expertise.
I would suggest that when you became aware that the patient plans to ski in the French Alps, your obligation is to remind the patient that he in turn has an obligation to disclose his medication and presumably underlying medical condition to his insurance company, and that failure to do so, may well invalidate his insurance cover.
In these insurance issues, the onus is on the patient to advise the company who decide whether or not to take on the risk. The doctor's remit, unless he has a specific expertise in the area, is to provide factual information with the patient's consent to inform the decision of the insurance company.