You've referred a middle-aged male patient with a change of bowel habits for a barium enema. Five weeks later you've received a letter from the consultant radiologist, saying that this man has now wasted two appointments for examination because he is unable to follow the simple instructions for bowel preparation. They are not going to send for him again. What do you do next?
DR VIBHORE PRASAD'S VIEW
You need to contact the patient as soon as possible. Try an open question, 'How did it go with your barium enema?', or 'Would you like to pop in to discuss this?'. This will give you a chance to assess the situation and uncover the underlying problem.
Perhaps the instructions were not clear, they did not reach his address, or perhaps he was simply one of the few patients who do not manage to clear their bowels with the bowel preparation he was advised to take. I would try to establish if any of these are the case in a face-to-face consultation if possible.
After finding out the facts, I would try to contact the consultant radiologist and explore his feelings. I would ask him what he thinks is the best course of action. Perhaps you can agree on a joint course of action and relay that back to the patient.
In summary, I would not allow any angst to be amplified by a hasty response or personal feelings, and I would take my time to do the right thing by all concerned - not forgetting that the patient comes first.
- Dr Prasad is a GP registrar in Banbury, Oxford
DR TILLMANN JACOBI'S VIEW
This is an uncomfortable situation and is likely to need a careful and diplomatic approach.
Sometimes as GPs we might feel or wish that sending a patient to investigations frees us to some extent of our responsibilities of care; this is not true.
If you were really worried about a significant outcome for this patient, demonstrated by an urgent referral, then a more active follow-up from your side would have been expected as good practice.
This man apparently went twice to the hospital but did not follow the instructions for preparing himself adequately. Unless there is a specific and foreseeable reason for difficulties on his part, for example visual or mental impairments, I would say it is up to the department to ensure clear guidance on the procedure and its requirements.
This letter with a dismissive 'discharge back to your care' is unlikely to improve co-operation and outcomes.
You will need to communicate this to the department in some form or take it to other relevant ports of call. Advice from your defence organisation and talking it through with colleagues could be helpful before you take any action.
Think of possible 'worst case scenarios', for example, the patient could have cancer with brain metastases which are affecting his memory and behaviour: Is it only possible to consider this scenario as a GP and not as a hospital doctor?
You should contact the patient for review as soon as possible and discuss what happened. He might be going through other emotional or social troubles and need more support.
- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005
DR DAVID CHURCH'S VIEW
I would first establish what happened.
Maybe the patient had other problems, for example, he could have been severely constipated or have anal strictures.
Another possibility is that the patient did not do the bowel preparation correctly.
Maybe he could not read the instructions or misunderstood them (if he is a non-English speaking patient).
If he had been feeling unwell, or if he had been too busy in the days leading to the procedure, he might have been unable to take the preparation.
If he had not been previously explained the importance of taking the preparation, he might have though that it was unnecessary.
This situation needs to be resolved urgently because it is important to find out the cause of his bowel habits change.
I would contact him and book him in for a consultation as soon as possible.
- Dr Church is a GP in Machynlleth, Powys, Wales
Remember that patient care is an ongoing process
1. Sending a patient to investigations does not free a GP from the responsibility of care.
2. An active follow-up from your side to any procedure is considered good practice.
3. Seek active contact with the patient as soon as possible and try to establish his side of the story.
4. Uncompliant patients might be in deep denial or be going through other emotional or social troubles and will therefore need extra support.
5. Explore if the patient has any physical condition that prevents him from preparing properly.
6. Contact the consultant and agree on a joint course of action and relay back to the patient for further discussion.