Practice dilemma - A prescription for steroid eye drops

The Dilemma: A new patient with episodic allergic conjunctivitis asks for steroid eye drops because 'nothing else works'.

The patient presented with episodic allergic conjunctivitis (Photograph: SPL)

You examine her eyes carefully, including ophthalmoscopy with fluorescein staining, and feel it would be safe to repeat the prescription, explaining it was for short-term use only. A few days later, her condition gets worse and she goes to the emergency eye clinic. The consultant comments that GPs should not initiate treatment with steroid eye drops as this should only be done by a specialist. The patient comes to see you and criticises you for not referring her before prescribing. You are aware of the shortand long-term dangers of steroid eye drops and think the consultant should not have made this comment. Should you take any further action?

A GP's response
Dr Barney Tinsley is a GP in Harrogate

In this situation, the prescription for steroid eye drops is made to a patient who has previously received them, has shown no adverse effects, and for whom a clear safety net has been laid. Safety-netting is crucial for all patients; advising them of a defined time period after which they should seek urgent review should they not be improving.

GPs with ophthalmological experience may have greater confidence in prescribing steroid eye drops than those without, and with careful safety-netting a short-term prescription can be justified. While I can understand the consultant's concerns, criticising the GP to the patient is unprofessional; they should have aired any grievances directly to the GP.

I would reassure the patient, with specific reference to the specialist's diagnosis, and with further plans for follow-up should their condition not resolve. I would not, however, register my displeasure to the consultant - in my opinion this gains very little, and solid relationships with secondary care colleagues are very valuable.

A medico-legal view
Dr Pallavi Bradshaw is a medicolegal adviser at the Medical Protection Society

It can be very difficult to manage a patient's expectation when they have fixed beliefs about their diagnosis and treatment.

While it is good practice to explore the patient's views, GPs should be cautious in acceding to requests which may not be in the patient's interests.

It is unfortunate that the ophthalmologist told the patient that you should not have prescribed the drops. Complaints often arise from comments made by other healthcare professionals which have been misinterpreted. It would be appropriate for you to contact the specialist to clarify what was said and why.

You could also explain the rationale for your management.

Although you felt that you had acted within your clinical competence, there may be a reason why the specialist felt steroid treatment was inappropriate.

You should take the opportunity to reflect on any advice and disseminate it through the 'significant event' process.

You should explain to the patient why a referral was not made as the GMC guidance Good Medical Practice encourages transparency following adverse incidents. You should express regret for distress and relay any lessons learnt, which may reassure the patient that you have acted reasonably.

A patient's opinion
Paul Weddell is an expert patient

The scenario is a good example of how the trust between the GP and their patient can be undermined. As a patient, I assume that my GP would never knowingly prescribe anything that could be a danger to me. On the other hand, I also realise that there are risks in taking any medicines.

I am also aware that many drugs can cause side-effects so I would be disappointed if my GP had not clearly explained the dangers associated with the treatment and that a referral to a specialist was an option before making a decision to proceed with the treatment.

The consultant is more likely to have superior knowledge and has a right to express his opinion, so the GP should treat this as a learning experience and apologise to the patient.

The nature of the apology is fundamental to the eventual outcome of the scenario; handled properly it can bring the matter to a satisfactory conclusion for both parties; handled wrongly, it can further undermine the patient's confidence in their GP.

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