Practice dilemma - Patient requests a second MRI scan

The Dilemma - Mr Jones has a history of anxiety and depression. He has visited the surgery three times in the past two weeks with minor illnesses and has been complaining of headaches for the past two years. Last year, a neurologist organised an MRI of his brain, which proved normal. The neurologist suggested he had anxiety issues, which angered Mr Jones. He is now requesting another scan, convinced he has a brain tumour. You offer to take a red flag history and examination, which he refuses, accusing you of palming him off. He insists he wants an MRI scan. What should you do?

Photograph: SPL
Photograph: SPL

A GP's view - Dr Judy Duckworth is a salaried GP in Cornwall
I would explore why he feels 'palmed off' and explain that my priority is to listen to his concerns and make the correct diagnosis. Has something triggered his specific fear of a brain tumour?

I would explain that tumours rarely cause such a long history of headaches without new symptoms developing.

I would agree to request a further MRI if we complied with established guidelines for headaches, which would depend on the outcome of a detailed history and re-examination.

While acknowledging that scans do occasionally miss tumours, this is rare. I would explain that MRI is highly sensitive, often finding unrelated pathology, which can result in further tests. Having one normal MRI has not allayed his fears; would a second scan reassure him further?

What alternative diagnoses has he considered, and why is he reluctant to contemplate that anxiety may be causing his headaches? Is he feeling stressed or low? I would recommend useful websites for information.

Ten minutes is insufficient time to resolve these issues. I would invite him to return in one week with a diary of his headaches, with the aim of agreeing a joint management plan, which could address any psychological issues.

A medico-legal opinion - Dr Sonya McCullough is a medico-legal adviser for the Medical Protection Society
The patient has a history of anxiety and depression which could potentially affect his capacity to make decisions.

Presuming there is not a capacity issue here, you can recommend an option for management that you feel is in the best interest of the patient.

However, you must not put pressure on him to accept your advice. If the patient asks for treatment that you consider would not be of benefit to him, you should discuss the issues with the patient and explore the reasons for their request.

If you still think the MRI would not be of overall benefit to the patient, you do not have to organise this investigation.

You should explain your reasons to the patient and explain any other options available to them. You must also give the patient an option to seek a second opinion.

In all these cases it is vital to fully document your discussion with the patient and the subsequent decisions made. The GMC provides useful guidance on this issue.

A patient's view - Elizabeth Brain is an expert patient
Mr Jones seems to have no confidence in MRI scans.

You could explain that MRI scanners have been around for a long time, are routinely used in medical diagnoses and have a good track record in discovering abnormal tissue structures.

You should explain that radiologists who interpret the images are highly trained. A repeat MRI is unlikely to lead to a different result. However, given that no diagnostic tool has a 100 per cent sensitivity, you might consider another neurology referral for reassurance.

Given that two separate techniques are unlikely to both give a false negative, you might agree to proceed with that course.

His history of anxiety and depression should be addressed in a subtle way. You might encourage him to take up interests which will give him a sense of tranquillity and personal achievement. You might explain that this would improve his life experience and that he would be far less likely to feel unwell.

Finally, you should assure him that you only have his best interests at heart and will always give him your fullest attention when it is needed.

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