Miss T is a regular caller to the out-of-hours service. In the past year she has made over 1,000 phone calls about chest pain and requesting home visits. These visits have not uncovered any emergencies. Her GP has issued a note saying that only immediate problems should be attended to because her mental health issues are being adequately managed. She calls, as usual, about a chest pain and requests a home visit. You are the doctor on duty.
What would you do?
Dr Anna Greenham's view
Frequent callers to out-of- hours providers can be very challenging.
They often call with symptoms that they know will ring alarm bells, making a home visit difficult to refuse.
The consultation is often lengthy and leaves the doctor feeling anxious. As with any other out-of-hours call a proper history should be taken.
Is this exactly the same pain as she usually gets, or is there something new? No mention is made of whether she has significant medical history or risk factors. After all, she could genuinely be having a heart attack.
Often frequent callers ring at times of stress, when drunk, or when lonely. The GP mentions that her mental health issues are being adequately managed. One could argue that if the frequent calls are related to her mental state, then more attention is needed.
If you think the call is unlikely to be due to an acute medical condition, it may be possible to reassure the caller. For this to work you will have to first assess the ideas, concerns and expectations of the patient, otherwise you may be wasting your time. Find out why she called today.
Ultimately, whether she receives a house visit or not will be a judgment call based on balance of probability, gut feeling and the results of your communication skills.
It may be as much about reassuring the doctor as reassuring the patient. Whatever the outcome, a very clear note should be made to the GP.
The caller should have an alert in their out-of-hours file. A case conference should be held and a management plan generated to help guide future consultations.
Dr Greenham is a GP locum in Northumberland. She qualified as a GP in 2006
Dr Barney Tinsley's view
This is a very tricky problem, and having worked regularly for a busy out-of-hours service I have faced it before.
It is clear that the bulk of Miss T's problems lie in the field of mental health. A doctor fulfilling the request is feeding into her illness, thereby the patient feels it is acceptable to continue calling and requesting visits.
However, we must be very wary of the 'cry wolf' scenario. An acceptable solution would be to offer the patient an out-of-hours appointment at the primary care centre.
Although many GPs would feel this is a waste of an appointment, and a real heartsink scenario, there is always a small possibility that this time the pain is of organic origin and the patient needs assessment.
The GP will also have access to previous encounters with this patient on the computer system, which could aid further judgments and management.
The patient's own GP could potentially help a great deal. Involvement of the mental health services, assignment of a community psychiatric nurse, or visits/telephone calls from the mental health nurse or community matron on, for example, a fortnightly basis may help stem the flow of calls to the out-of-hours service.
Dr Tinsley is a salaried GP in Bradford. He qualified as a GP in August 2005
Dr Fatima Hussein's view
It is a very difficult scenario, but I imagine it is a common one. As a GP, my patient's health is the first priority, and it is wise to take Miss T's complaint seriously every time she rings.
However, acknowledging her history is important at the same time.
Even bearing in mind that her previous claims of chest pain did not reveal any emergencies it is still important to take a careful clinical history.
It would help to look at her previous notes and see what other GPs thought about her chest pain and how they dealt with her in the past. Did she receive a home visit every time she rang before?
The other important thing to know is why she asks for home visits every time, and why she is claiming she has chest pain.
Is it an exacerbation of her mental problem, is there a hidden agenda? Who is with her at home? Is she mentally competent? Is she aware of her previous 1,000 phone calls? Does she have history of making similar calls to other healthcare agencies?
After taking a careful history over the phone, one might suggest she could ring an ambulance, or arrange an ambulance for her if she is really in pain.
Dr Hussein is a GP registrar in Nottingham
- This topic falls under section 13 of the GP curriculum 'Care of People with Mental Health Problems', www.healthcarerepublic.com/curriculum
Miss P is seven weeks amenorrhoeic. She is convinced that she is pregnant and has come to see you because she has a light bleed. She is not in pain and has not passed any clots. She demands that you book her for an early pregnancy assessment ultrasound scan at the hospital. She refuses to have a pregnancy test, saying that a doctor friend of hers said all she needs is a scan.
What would you do?
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