Patient with a chronic illness

A patient is taking up your time with queries. What should you do?

The Problem
A patient of yours has been diagnosed with a rare, progressive neurological condition. As a result she attends almost weekly and calls you frequently with any concerns about possible new related symptoms. She says you are a lot more supportive than any of the other doctors in the surgery have been, even since before her diagnosis. She seems unaware that she is taking a lot of your time. What do you do?

Dr Afolabi Olaleye's view
I have a duty of care not only to this patient but to the whole of my patient population. It is not in the best interests of myself or my patients to experience a burnout.

It is therefore a fine balancing act not to alienate this particular patient, who is probably desperately in need of support and accurate, up-to-date information.

A demonstration of empathy and a declaration of my limited knowledge of this rare neurological condition could probably ease the pressure.

In addition, I would take active steps to point her in the right direction by suggesting reliable and peer-reviewed sources of easily digestible information on the internet.

I would also write to the consultant in charge for patient information leaflets or similar materials that could assist the patient in understanding the disease. Finally, I would provide her with the contact details of a relevant patient group.

Hopefully, all the above measures will prevent a deterioration of the doctor-patient relationship.

Dr Olaleye is a GP in Rochester, Kent. She qualified in as a GP in February 2006

Dr Jane Bowskill's view
I would find out as much as I could about her illness, including speaking to her consultant, and also if there is a patient support group or helpline.

Then I would arrange a planned longer follow-up appointment with her and a partner or friend, and find out how much she knows and what she has been told.

It is almost impossible to retain information when confronted with a devastating diagnosis, and she will need a lot of support and explanation. This may initially need to be repeated until she fully understands the diagnosis.

Recently, I have found that hospitals seem to overload patients with information at their first appointment. I had a patient with a new, very early breast cancer who was given information on trastuzumab, wigs and lymphoedema before she even got an appointment for her lumpectomy.

If she feels more comfortable seeing you, offer to do so on a planned basis, perhaps a fortnightly appointment to begin with, and advise her that any queries between these times will not necessarily be dealt with by you.

Dr Bowskill is a locum GP and school doctor in Hampton, Middlesex. She qualified as a GP in 1982

Dr Barney Tinsley' view
In this instance, the GP should be aware that this patient is bound to have constant health concerns, given that the underlying condition is progressive.

A patient with a significant and progressive neurological diagnosis is likely to need increasing input from the multi-disciplinary team as their condition deteriorates.

Initial steps might be to look for local and national support groups. Patients can receive comfort and information from others with a similar condition, and may even be able to access financial and home-related assistances through these groups.

The internet gives a patient the opportunity to obtain further information, and communicate with others, but can sometimes create more questions than answers.

In our practice, a 'lead GP' might be assigned to a patient such as this; we have several patients with complex medical needs whom we would assign a named GP. This system allows the GP to define the boundaries in the relationship with the patient; for example, planned telephone consultations and routine home visits.

We encourage our reception staff to alert the lead GP to any issues involved in the care of the individual, and there have been occasions when the patient has direct access to the GP (for example mobile phone number).

We have often involved the district nurses and community matrons in the care of these patients alongside the lead GPs, giving the patient the opportunity to access specific care issues as their need arises.

This strategy works extremely well, with regular updates on each patient happening at our monthly primary healthcare team meetings.

It is obviously prudent for a GP involved in the care of a patient with a complex diagnosis to be 'up to speed' with the clinical thinking in that condition.

In some rare syndromes, specific clinical information may be difficult to come by, and the answer 'I don't know' may be a valid one when questions are asked. Early referral to a neurologist would enhance the overall multidisciplinary team care for the patient.

Dr Tinsley is a salaried GP in Bradford. He qualified as a GP in August 2005

This topic falls under section 1 of the GP curriculum, 'Being a GP',

Next Problem
You take a telephone call from the carer of a 72-year-old diabetic man in sheltered accommodation. The carer is concerned that the man has not been doing his blood glucose tests and that his blood glucose is now 18mmol/l. When you speak to the man he says he feels unwell and just wants a lie-down, but he flatly refuses to be admitted to hospital. What would you do?

Email with your replies by 27 June 2008. We will pay £25 for each reply published.

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