A problem shared - Should GPs give in over referrals?

A teenager with whiplash and his father want a referral for physiotherapy, but you do not agree. What do you do?

THE PROBLEM

A 17-year-old boy comes in with his father to consult you for an uncomplicated whiplash injury. A previous visit to A&E suggested physiotherapy might be needed. Clinically you disagree, but the father works in the local hospital management and needs a note from you to 'make sure that it will be dealt with'. What do you do?

- Dr Raj Thakkar's view

If it is clear that a referral to physiotherapy is not appropriate, why refer? Referring for inappropriate management may be considered a failure in your duty of care to your patient. Ethically, a referral is unacceptable.

However, the difficulty is conveying this to the father. At 17, the son's views are valid and he is legally able to consent for treatment. If he refuses treatment, his parents can override his wishes but, in this case, physiotherapy is not being offered in the first place. If he refuses it, without coercion from his father, then the father does not have an argument.

It is important to keep the father on side. Entering into an argument will not look professional, will destroy the doctor-patient relationship and may be politically damaging, given the father's position. However, it is unprofessional of him to use his position as leverage and unprofessional of you if you bow to it.

Obtaining the A&E notes is pivotal. You can interpret what the A&E officer said, which may clear up any misunderstanding. If these notes are currently unavailable, you can stall while you obtain it. Hopefully, justifying your clinical opinion is helpful and may be enough if the father is amenable.

If not, a second opinion may be a sensible option.

- Dr Thakkar is a GP in Woodburn Green, Buckinghamshire

- Dr Mini Nelson's view

This is a difficult consultation for several reasons. First, facing a father and a teenage son together is challenging because they will come with different agendas. Second, in a 10-minute appointment, eliciting ideas, concerns and expectations from both father and son is difficult, and crucially it is important to recognise that the 17-year-old boy is the patient, and that he needs to be involved in all decision making.

I would try to establish good rapport with father and son from the start.

Once a diagnosis of whiplash injury is made from history and examination, I would try to gauge how much they know about whiplash injury. I would then discuss the management of whiplash injury with the aid of patient leaflets which particularly emphasises patience, pain relief and early mobilisation of the neck. I would explain the role of physiotherapy for unresolved symptoms and severe whiplash injury.

I would aim to reach a combined management plan and arrange a follow-up appointment to allow them to clarify doubts.

- Dr Nelson is a freelance GP in Norwich, Norfolk.

She qualified as a GP in February 2006

- Dr Tillmann Jacobi's view

Depending on your confidence and personality, you could be assertive and stick to your clinical judgment. By refusing to get involved in an unnecessary referral you may, however, risk confrontation. If you allow the father to manipulate you, you are likely to end up in a difficult situation.

You should try to seek agreement, consent and co-operation. However, you also have a duty to look at the wider issue of any potentially inappropriate patient demand.

The patient is likely to benefit little at this stage beyond your own sensible advice, and a referral could medicalise a relatively trivial trauma. Do not forget that there might be an argument about who is to blame for this accident - you do not want to add fuel to an unnecessary battle.

The patient's autonomy is compromised because he is apparently not speaking for himself.

You may not have the time to think through all of these matters during the consultation, but you could defer the issue and offer another appointment for review in a few days, perhaps with the patient alone.

Keep clear records in case you feel there is a chance of a complaint and for your future reference.

- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005

LEARNING POINTS

Aim for a good rapport without being manipulated

- Referring for inappropriate management may be considered a failure in your duty of care to your patient.

Stick to your clinical judgment. If in doubt, ask a colleague for a second opinion.

Entering into an argument will look unprofessional, and will destroy the doctor-patient relationship.

Obtaining the A&E notes is pivotal. You can interpret what the A&E officer said, which may clear up any misunderstanding.

Try to reach a combined management plan and arrange a follow-up appointment.

Keep clear records in case there is a complaint.

NEXT PROBLEM

A dentist rings you to enquire about a possible clotting condition in a teenage patient of your practice who is due to have a wisdom tooth extraction the next day. The dentist says there is a possible family history of a 'clotting disorder', but she does not really understand the details. What do you do?

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